Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 227 - RULES FOR ESTABLISHMENT AND OPERATION OF CREMATORIA
Appendix 144-227-B
Current through 2024-38, September 18, 2024
MONTHLY CREMATORIUM REPORT
Please complete all of the following data components. Please print legibly or type.
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FACILITY INFORMATION
Facility Name: ________________________________________________
Facility Location, Street: ________________________________________________
Facility Location, Town/City: ________________________________________________
Facility Mailing Address: ________________________________________________
Facility Operator/Authority: ________________________________________________
Telephone: ______________________ E-mail: ____________________________________________
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OPERATIONS SUMMARY
1. Reporting Period: Month ending on (MM/DD/YYYY) ____________________________
2. During this reporting period, the subject facility cremated the remains of ________ persons.
I, _______________________, Facility Operator/Authority for the subject facility, hereby state that this report is
(Print Your Name)
accurate to the best of my knowledge. I further stipulate that I am aware that deliberate falsification of the information herein shall be sufficient cause for an audit of the subject facility's records.
_______________________________________________ __________________________
Signature of Facility Operator/Authority Date
