Region 1: EPA New England

Report Form

Within the 30 days the following information must be included in the report sent to EPA:

Burial at Sea Report Form
Name of Deceased:
Date of Birth of Deceased:
Date of Death of Deceased:
Date of Burial/Scatter:
Types of Remains:	Cremated Non-Cremated
Date of Cremation (If Applicable):
Location of Burial/Scatter:
Latitude
Longitude
Distance from shore (min. of 3 nm)
Depth of water
Vessel Name:
Vessel Point of Contact, Name/Address/Phone/E-mail:
Port of Departure:
For Non-Cremated Remains: Did the remains appear to rapidly sink to the ocean floor	Yes No
Director or Person(s) Responsible for BurialArrangements, Name/Address/Phone/E-mail:
Family Member or Responsible Party, Name/Address/Phone/E-mail:
Please submit your e-mail address. *(Required)

**Please Send Photocopies of Burial, Cremation or Other Permits Required by Appropriate Civil Authorities in an Email to Ann Rodney (rodney.ann@epa.gov). Please List Name of Deceased in the Subject Line.

OR please send the same information to:

Ann Rodney (rodney.ann@epa.gov)
Burial at Sea Coordinator
US EPA Region 1
5 Post Office Square, Suite 100
Mail Code: OEP06-1
Boston, MA 02109-3912
(617) 918-1538

Serving Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont, & 10 Tribal Nations

Report Form

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