0001179110-21-007131.txt : 20210629 0001179110-21-007131.hdr.sgml : 20210629 20210629180118 ACCESSION NUMBER: 0001179110-21-007131 CONFORMED SUBMISSION TYPE: 4 PUBLIC DOCUMENT COUNT: 1 CONFORMED PERIOD OF REPORT: 20210628 FILED AS OF DATE: 20210629 DATE AS OF CHANGE: 20210629 REPORTING-OWNER: OWNER DATA: COMPANY CONFORMED NAME: BUCKMAN PAUL CENTRAL INDEX KEY: 0001215243 FILING VALUES: FORM TYPE: 4 SEC ACT: 1934 Act SEC FILE NUMBER: 001-40518 FILM NUMBER: 211059462 MAIL ADDRESS: STREET 1: 12988 VALLEY VIEW RD CITY: EDEN PRAIRIE STATE: MN ZIP: 55402 ISSUER: COMPANY DATA: COMPANY CONFORMED NAME: Miromatrix Medical Inc. CENTRAL INDEX KEY: 0001527096 STANDARD INDUSTRIAL CLASSIFICATION: BIOLOGICAL PRODUCTS (NO DIAGNOSTIC SUBSTANCES) [2836] IRS NUMBER: 271285782 STATE OF INCORPORATION: DE FISCAL YEAR END: 1231 BUSINESS ADDRESS: STREET 1: 10399 WEST 70TH STREET CITY: EDEN PRAIRIE STATE: MN ZIP: 55344 BUSINESS PHONE: (612)202-7026 MAIL ADDRESS: STREET 1: 10399 WEST 70TH STREET CITY: EDEN PRAIRIE STATE: MN ZIP: 55344 4 1 edgar.xml FORM 4 - X0306 4 2021-06-28 0 0001527096 Miromatrix Medical Inc. MIRO 0001215243 BUCKMAN PAUL 1039 WEST 70TH STREET EDEN PRAIRIE MN 55344 1 0 0 0 Common Stock 2021-06-28 4 C 0 3000 A 8555 I By Paul R. Buckman Revocable Trust Series B-2 Preferred Stock 2021-06-28 4 C 0 3000 D 2021-05-21 Common Stock 3000 0 I By Paul R. Buckman Revocable Trust Each share of Series B-2 Preferred Stock had no expiration date and automatically converted into one share of Common Stock upon the closing of the Issuer's initial public offering. /s/ Elise B. Houser, Attorney-in-Fact 2021-06-29