Fillable Printable Form 653007
Fillable Printable Form 653007
Form 653007
For validation only
X
For office use only
24003 Certificate date
Certificate number
Funeral Establishments
Certificate of Removal
Registration Application
Funeral establishments can use this form to apply for certificate of removal
registration.
Send this completed form and a check or money order payable to the
Department of Licensing for $30 for an initial application or $15 for an
annual renewal to: Funeral and Cemetery Licensing, Department of
Licensing, PO Box 35001, Seattle WA 98124-3401
Establishment
PRINT or TYPE Establishment name Unified Business Identifier (UBI) number
Street address
City State ZIP code County
Mailing address (if different)
City State ZIP code County
(Area code) Daytime telephone number Email
Location manager or contact person name (Last, First, Middle initial)
Type of business (check one)
Sole proprietor Partnership Corporation
Sole proprietor, partner, corporate officer – Attach additional pages as required
1 Name Title (sole proprietor, partner, corporate officer)
Address, City, State, ZIP code
2 Name Title (sole proprietor, partner, corporate officer)
Address, City, State, ZIP code
3 Name Title (sole proprietor, partner, corporate officer)
Address, City, State, ZIP code
4 Name Title (sole proprietor, partner, corporate officer)
Address, City, State, ZIP code
5 Name Title (sole proprietor, partner, corporate officer)
Address, City, State, ZIP code
Declaration – Must be signed by owner, partner, or corporate officer
I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.
Title
Date and place Signature of proprietor or corporate officer
FE-653-007 (R/7/15)WA Page 1 of 2
Click here to START or CLEAR, then hit the TAB button
When you have completed this form, please print it out and sign here.
Funeral establishments licensed in states that border Washington State, with similar laws, may apply for this registration
for the limited purpose of removing human remains from Washington State prior to submitting a Certificate of Death.
Each branch of a funeral establishment is considered a separate establishment and must be registered as a fixed place of
business.
The conduct of funeral directors, embalmers or any other person employed by or acting on behalf of a removal registrant
is the direct responsibility of the holder of the Certificate of Removal Registration.
The Funeral and Cemetery Board may impose sanctions on the holder of a Certificate of Removal Registration if the
registrant is found to be in violation of any death care statute or rule.
Certificate of Removal Registrations expire on January 31, or as otherwise determined by the Director.
Certificates of Death, Notices of Removal, and Disposition Permits are governed by the Department of Health under
RCW 70.58.160 and 70.58.230.
FE-653-007 (R/7/15)WA Page 2 of 2
