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

Current through 2024-51, December 18, 2024

Appendix 144-227-C

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

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