C.M.R. 10, 144, ch. 227, app 144-227-B

Current through 2024-51, December 18, 2024

Appendix 144-227-B

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

C.M.R. 10, 144, ch. 227, app 144-227-B