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-C
Current through 2024-38, September 18, 2024
| Department of Health and Human Services Maine Center for Disease Control and Prevention 286 Water Street # 11 State House Station Augusta, Maine 04333-0011 Tel: (207) 287-5689 Fax: (207) 287-3165; TTY: 1-800-606-0215 |
ANNUAL 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: Fiscal [] Calendar [] Year ending on _______________________ (MM/DD/YYYY)
2. During this reporting period, did any changes to the organization, the structure, and/or the equipment used at the subject facility change" Yes [] No []
If "yes," please provide a detailed description on a separate page or pages.
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
