Georgia Board of Funeral Service

Initial and Second 90-Day Grace Period Request Form

Initial Request
Thornton Funeral Home
Name of Firm: ___________________________________ Establishment Number: FEST000541
______________________________
26 N Miller St
Mailing Address: _________________________________ thorntonsfuneralhome@gmail.com
Email: _______________________________________________
Hazlehurst, GA
City & State _____________________________________ 31539
Zip Code: ____________________________________________
James Benjamin Melton
Former FDFCC: _________________________________ July 18, 2023
Date last served as FDFCC: _____________________________
X
Apprentices supervised by former FDFCC? ______Yes _____No

List the licensed Funeral Director or Directors who will be serving the firm during the Grace Period:
Bryan Melton
Name: _________________________________________ FD4841
License Number: _____________________________________

Name: _________________________________________ License Number: _____________________________________

July 18, 2023

Initial Request Date: _____________________________ ____________________________________________________
Signature of owner or person authorized to act for ownership

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Second Request
List the licensed Funeral Director or Directors who will be serving the firm during the Grace Period:
Bryan Melton
Name: _________________________________________ FD4841
License Number: _____________________________________

Name: _________________________________________ License Number: _____________________________________

I understand that if an approved FDFCC candidate is not presented to the Board by the end of the second 90-day grace
period, no further consideration may be given, and I agree to suspend operations of the establishment until an approved
FDFCC can be presented to the Board. No further extension may be granted for the next two years.

October 11,2023
Second Request Date: ____________________________ _____________________________________________________
Signature of owner or person authorized to act for ownership

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(Board Use Only)

Resignation or notification of FDFCC departure received? _______Yes ______No Date: _______________________

Initial 90-day grace period Second 90-day grace period

Begins: _____________________________________ Begins: ___________________________________________

Ends: _____________________________________ Ends: ____________________________________________

(Expires 90 days from the last date worked by former FDFCC) (Expires 90 days from the expiration of the 1st 90-day period)

Approved / Denied Date: _____________________ Approved / Denied Date: ___________________________

___________________________________________ __________________________________________________
Authorized Signature Authorized Signature