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207.892.1850 8
Our variety of manual forms come Edge
Clued or Snap-a-part with 2-5 parts. 1 or
2 sided printing is also available.
Standard 20# Carbonless
• Standard Color Sequence (2-4 Parts)
White, Canary, Pink & Gold
• Standard Color Sequence (5 Parts)
White, green, Canary, Pink & Gold
• Standard Ink Colors
Black, Reflex Blue, 347 Green,
208 Burgundy, 032 Red & 185 Red
(All other Pantone colors available at
additional cost)
• Additional Services Available
- Wrap Around Covers
- 1, 2, 3 & 4 spot color printing
- Padding, Drilling & Numbering
DECEDENT
PARENTS
INFORMANT
1a. FIRSTNAME 1b. MIDDLENAME 1c. LASTNAME 1d. JR.,etc.
2. DATEOFDEATH (Mo,Dy, yr) 3. SEX 4. SOCIALSECURITYNUMBER 5a. AGE (Yrs) 5b. UNDER1YEAR 5c. UNDER 1DAY 6. DATEOFBIRTH(Mo,Dy,Yr)
Months Days Hours Minutes
LastBirthday
7. BIRTHPLACE (City andState orForeignCountry) 8. WASDECEDENT 9.PLACEOFDEATH(Check onlyone)
EVER INU.S. YES HOSPITAL: DOA OTHER: NursingHome Residence
ARMEDFORCES? NO Inpatient ER/Outpatient Other(Specify)
10. FACILITYNAME(If not institution,give street andnumber) 11.COUNTYOFDEATH 12. CITYORTOWNOFDEATH
13. MARITALSTATUS 14. MOSTRECENTSPOUCE (Ifwife, 15. DECEDENT’SUSUALOCCUPATION (Give kind ofwork 16. KINDOFBUSINESS / INDUSTRY
givemaiden name) doneduringmost ofworking life. Donot use retired.)
Married NeverMarried Living Deceased
Widowed Divorced
17. DECEDENT’SEDUCATION(Specify onlyhighestgrade completed) 18. ANCESTRY-French,English, Irish,etc.(Specify) 19. RACE-American Indian,Black,White,etc.(Specify)
Elementary/Secondary College
(0 - 12grades) (1 - 4 or 5+ years)
20. RESIDENCESTATE 21. RESIDENCECOUNTY 22. RESIDENCECITYORTOWN 23. RESIDENCESTREETANDNUMBER
24a. FIRSTNAME 24b. MIDDLENAME 24c. LASTNAME 24d. JR., etc.
FATHER’S
25a. FIRSTNAME 25b. MIDDLENAME 25c. MAIDENSURNAME
MOTHER’S
26. INFORMANT -NAME(Type orPrint) 27. MAILINGADDRESS (Street andNumber orRuralRouteNumber,CityorTown, State, ZIPCode)
28. RELATION
31. METHODOFDISPOSITION: ¨Temporary ¨Burial ¨ Cremation ¨ Removal ¨UsebyMedical ¨ Other(Specify) 32. WASBODYEMBALMED
Storage FromState Science ¨YES ¨ NO
33a. PLACEOFDISPOSITION(Name ofCemetery,Crematory,orOtherPlace) 33b. LOCATION (City,Town,State) 33c.DATEOFDISPOSTION .)
29. T.O.D. 30. PHONE
COPIES #
Biographical Information
Name &Age Place of Birth:
Parents:
Schooling: Military:
Employment History:
ReligiousAffilation: Church:
Clubs & Organizations:
Hobbies:
Predeceased by:
Survivors:
In Lieu of Flowers:
HobbsSouthPortland HobbsSouthPortland
FUNERAL ARRANGEMENTS
Name:
DateofDeath: Time:
PlaceofDeath:
Residence:
City: State:
File #:
MortuaryTrust ID:
Amount:
Director:
Zip:
Informant: Phone:
Address: Relationship:
City: State: Zip:
Need Done
Date Day Time Place
Date Day Time Place
Date Day Time Place
Date Day Time Place
Service Details: Funeral Memorial Graveside Public Private None
Visitation:
Service:
Reception:
Burial:
Arrangements Disposition: Cremation Burial Tomb
Church:
Clergy:
Casket: Open / Closed
Vault:
Urn:
Flowers:
Hairdresser:
Organist:
Sexton:
Reg.Book:
PrayerCards:
Prayer:
Reception
Hostess:
Caterer:
FoodOrder:
Veterans Branch ofService:
Obituary/Notice: Photo /NoPhoto Date toRun
Physician:
Phone #:
Fax #:
EDRS File #:
MERelease
Flag
Honors
Marker
Benefits
Notice:
Paper:
WindhamFireRescueDepartment
375GrayRoad
Windham,Maine 04062
Tele # (207) 892-1911 Fax # (207) 892-0544
FireAlarmDetection&SuppressionActivationReport
Date:___________ Incident#_________BusinessNameorResidence:_________________________________
Address:_______________________________________________TimeofAlarm:________________________
ContactName:___________________________Title:________________Phone:_________________________
PersonWritingReport:____________________OccupancyUse:______________________________________
Situation foundupon arrival.Please check allboxes that apply.
HumanElement. IncidentComments.PleaseNoteAll Issues.
FireAlarm activation intentional
FireAlarm activationunintentional
FireAlarm activationunknown
Sprinkleractivation intentional
Sprinkleractivationunintentional
Sprinkleractivationunknown
FireAlarmorSprinklerSystem condition.
FireAlarm systempartially shutdown
FireAlarm system completely shutdown
FireAlarm left in“trouble” condition
Sprinklerpartially shutdownor impaired
Sprinkler completely shutdown
DryPipeSystem tripped
Dry sprinkler left inawet condition
Have you verified that thepropertyownerormanagerhasbeennotifiedof theproblembefore you
cleared the scene? Yes o No o
HasFireAlarmbeennotified of the situation, and the informationhasbeen logged into the incident?Yes o No o
HasFireAlarmSystembeen restored? Yes o No o
Signature ofOccupancyOwnerorManager: ______________________________________________
OfficeUseonly:FollowupRequired? Yes o No o
FollowupDate: ______________F.D.Personwho followedup______________________________
WhiteCopy forpropertyowner Yellow&PinkCopy forFireDepartment
Important Information forNewPatientsofCommunityDental
1. In ord r to best serve you as a patient ofCommunityDental please complete the attachedpaperwork and bring ormail it to the centerwhere you are seeking services.
CommunityDentalBiddeford, 57BarraRd.,Suite 3,Biddeford,ME 04005 (207) 282-1305
CommunityDentalFarmington , 131FranklinCommons,SteI,Farmington,ME 04938 (207) 779-2659
CommunityDentalLewiston, 177MainSt., Lewiston,ME 0424 7) 777-7442
CommunityDentalPortland , 640BrightonAve,Portland,ME 04102 (207) 874-1028
CommunityDentalRumford, 60 LowellSt,Rumford,ME 04276 (207) 369-3600
2. On the day of your appointment, please arrive 10minutesbeforeyour appointment time. It is
required that you bring yourinsurance cardwith you to each appointment.
3. A parentorguardianmust accompany patients under 18 years of age and remain at theCenter
during the length of the appointment.
4. Paymentfor dental services is due at the same time you receive the dental care. There is a $25
fee for any check payments returned for non-payment.
5. If you are requesting consideration for our income based sliding fees, youmust complete the
sliding fee application (on page 3) and include copies of all proof of household income.Thismay
include:
• A copyof yourmost recentTaxReturn,currenthouseholdW-2sorpay stub(s) that
includes year todate income total.
• A copyof yourTANFCheck,SSI/SSDICheck,RetirementCheck,VABenefitsorBank
statementofDirectDeposit for anyof the above
• Alimony, child supportpayment,CityorGeneralAssistanceVoucher
Proof of incomemust be updated annually. Full feeswill be applied if documentation is not
receivedwith application.
ImportantBrokenAppointmentNotice
Missed appointments prevent patients from getting the care they need. Community
Dentalmay restrict patients from scheduling appointments if they have broken an
appointment. An appointment is considered to have been broken if:
1. The patient fails to appear for the appointment, or
2. The patient arrives too latefor a scheduled appointment, or
3. The patient cancels an appointmentwithless than 24hoursnotice
CheckoutourWebsite
HOUR GLASS
(207) 775-9915
619MainStreet,SouthPortland,ME 04106
ACCOUNT
NO. AGENT
NO. PURCHASE
ORDERNO. DATE
CONTRACTOR LICENSE# STATESALESTAX#
CUSTOMERSTATETAXOREXEMPTNO. CUSTOMERFEDERALTAX . SOURCE SALESMAN I.D. ORDERTAKENBY
INSTALLEDBY FEDERALTAX .
10
INSURANCEPROOFOFLOSS
VEHICLE INFORMATION
SOLDTO: CUSTOMER:
INSURANCECO:
INSURANCECO:
PHONENO.
POLICYNAME
AGENTNAME
AGENTPHONE
POLICYNO:
CLAIMNO:
CAUSE&
LOSS LOCATION
VERIFIEDBY
DATEOFLOSS DEDUCTIBLE
NAME
ODOMETER
MODEL
LICENSE
YEAR
VEHICLE
DOORS
IMPORTANT WARRANTYTERMS ON BACK
CUSTOMER’SSIGNATURE
CUSTOMER’SSIGNATURE TOTALSALE
TERMS
WORKAUTHORIZATION
Iherebyauthorize theabovework tobedone togetherwith thenecessarymaterial,but request that you contact
rvice exc
ASSIGNMENTOFPROCEEDSANDAUTHORIZATIONTOPAY: Replacement or repair
of the glass inmy automobilehasbeen done tomy satisfaction. I authorizemy insurance company
to release policy, coverage andother information toHourGlass. I hereby authorize anddirect
my insurance company topay this invoicedirectly.HourGlass and I assign any and all claims in
connectionwith this automobileglass installation or repair againstmy insurance company and all
policyproceedsdue for this installation or repair toHourGlass. I agree that ifmy insurer should
ignore thisdirective to pay and the assignmentof thepolicyproceeds and issue payment tome that
Iwill immediately forwardpayment toHourGlassby either endorsing the check that I receiveover
toHourGlassorpayingHourGlass an amount equal towhat I received. If I donothave insurance
coverage. I agree topay forworkmyself.
TERMS:NET30DAYS,SERVICECHARGEOF 1 1/2%PERCENTPERMONTH (18%PERYEAR)WILLBECHARGEDONOVERDUEACCOUNTSTRANSACTION ISSUBJECTTOTERMSANDCONDITIONSONREVERSESIDE
27-2627546
January 2012
WindhamFire -RescueDepartment
375GrayRoad
Windham,ME 04062
Location ________________________________ IncidentNumber _______________
Time ofAlarm ___________________________ Time ofMeasurement ___________
Questions to askOccupants:
Are there anymembers of the household feeling ill?
Headache YES NO Fatigue YES NO
Nausea YES NO Dizziness YES NO
Shortness ofBreath YES NO Confusion YES NO
Other ____________________________________________________ YES NO
A “YES” response to any of thequestions requires andEMS evaluationby theparamedic.
Do you feel better away from the house? YES NO
What applianceswere on at the time of activation? _________________________________
What applianceswere in use in the last 24 hours? __________________________________
GasDetectionMeterChecklist
Area of RoomLocation PPMReading Area of RoomLocation PPMReading
OutsideReading GasDryer
Entry
HotWater
Heater
PortableHeater Furnace
Refrigerator Chimney
Stove /Oven Fireplace
Stove /Hood Garage
CODetector BBQGrill
CODetector Information ____________________________________________________________________
Make ____________________________________ Model _____________________________
Name of Individual handling theCOmeter ______________________________________________________
Officer completing the checklist _______________________________________________________________
Received by ______________________________________________________ Date: ___________________Homeowner orTenant
This checklist shall be completed for allCarbonMonoxide detector activations.
The completed sheet shall be completed and returned to the office.
The owner or occupant shall be given part two of the sheet
WhiteCopy toOffice CanaryCopy toCustomer
January 2012
WindhamFire -Rescu Department
375GrayRoad
Windham,ME 04062
Location _____ IcidentNumber _____
Time ofAlarm _____ Time ofMeasurement _____
Quesion to askOccupants:
A there anymembers of th usehold feeing ill?
Headache YES NO Fatigue YES NO
Nausea YES NO Dizziness YES NO
Shortness ofBreath YES NO C fusion YES NO
Other _____ YES NO
A “YES” respnse t any of thequestions rquires andEMS evaluationby theparamedic.
Do you fel betteraway from th house? YES NO
What appliancswere onat the time of activation? _____
What appliancswer i us in the last 24 hours? _ _____
GasDetectionMetrChecklist
Area of RomLocation PPMReading Area of RomLocation PPMReading
OutsideReading GasDryer
Entry
HotWater
Heater
Portabl Heater Furnace
Refrigerator Chimney
Sto /Oven Fireplace
Stove /Hood Garage
CODetector BBQGrill
CODetect Infrmation _____
Make _____ Model _____
Name of Individua handling theCOmeter _ _____
Officer completing the checklist _____
Received by _____ Date: _____
Homeowner orTenant
This checklist shall be completed for allCarbonMonoxide detetor activations.
The completd eet shall be completed and returnedt th office.
Th owner or occupnt shall begiven part two of thesheet
Received subject to the classifications and tariffs in effect on the date of the issue
of thisBillofLading, thepropertyasdescribedhere inapparentgoodorder,except
as noted (contents and conditions of contents of packages unknown), consigned,
and destined as indicated here which said carrier (the word carrier being
understood throughout this contract as meaning any person or corporation in
possession of thepropertyunder the contract)agrees to carry to theusualplaceof
delivery at saiddestination ifonhis route,otherwise todeliver toanother carrier on
the route to said destination. It ismutually agreed as to each carrier of all or any
of said property over all or any portion of said route to destination and as to each
party at any time interested in all or any said property, that every service to be
performed hereunder shall be subject to all the bill of lading terms and conditions
in the governing classification on the date of shipment.
Shipper hereby certifies that he is familiarwith all of the bill of lading terms and
conditions in the governing classification and the said terms and conditions are
hereby agreed to by the shipper and accepted for himself and his assigns.
Dba:FreeRangeFish&Lobster
Phone: (207)774–8469
Fax: (207) 774–8466
Dba:MaineStreamSeafood
Phone: (207) 871–9020
Fax: (207) 871–5030
FREEDOMFISH,LLC
450CommercialStreet
Portland,ME04101
SHIPPERORCONSIGNOR
StraightBillofLading
DELIVERING
CARRIER:
TO:
Consignee
Street
Destination
Ship to
AWB
ZipCode
DATE
TOTES
IN: OUT:
OrderBy PackedBy
No.
Packages
Extended
Price Product Price Lbs.
Quantity H.D. H.A. ORIGINALSHIPPER TYPE
FREIGHT: ❏PREPAID ❏COLLECT TOTAL ➤
WHITE -OFFICE CANARY -CUSTOMER PINK -CARRIER GREEN -CARRIER BLUE -CARRIER
XXXXX
DATE
21GREATREPUBLICDRIVE
GLOUCESTER,MA01930
(978) 330-3051 •FAX (978) 513-8426
CUSTOMERNAME
LOCATION ofTRANSACTION
DRIVER
CONTAINER TOGLOUCESTER BALANCE
CRATES
PALLETS
BARRELS
OTHER
TOREORDERCALL: (207) 892-1850 • MAINE LABEL&PRINTING • POBOX 938,WINDHAM,ME 04062
CRATE INVOICE
TOCUSTOMER
GLOUCESTERSEAFOODPROCESSING (PLEASEPRINTNAME)
CUSTOMER (PLEASEPRINTNAME)
COMMENTS:
XXXXX
VATS