Information Required to Process Funeral

Muslim Funeral Home of Rockford

First Call Record

 

 

 

Name of Deceased:  __________________________________________________________________Race__________

 

Date of Death:  _____________________________  Time of Death:  _______________________________ US army____

 

Social Security # of Deceased: ____________________________________  Date of Birth of Deceased: ______________

 

Place of Death:  ___________________________________________________________  Phone: ___________________

 

Address:  ________________________________  City: _____________________________  State: _____ Zip: _________

 

Phone:  __________________________________________ Cell:  ____________________________________________

 

Doctor:  ________________________________________  Address: ___________________________________________

 

City:   __________________________________ State:  _______  Zip:  _________  Phone:  ________________________

 

Next of Kin:____________________________________________ Relationship:__________________________________

 

Next of Kin: Phone Number: ___________________________________________________________________________

 

Is the family present?  Are they ready for us to come?  Would you like the director to call you back with an ETA?

 

Person Receiving Call:  ___________________________  Date:  ___________________  Time : ____________________

 

Marital status at the time of death_______________________ surviving partner maiden Name ______________________

 

Father Name Full________________________________ Mother Name Full _____________________________ (maiden)

 

Mailing address _____________________________________________________________________________________

 

Disposition: ________________________________________________________________________________________

 

Decedent Education________________________Occupation__________________Bussiness/Industry________________

 

Please obtain a copy of ID and social security of decedent

To Print please click the Icon, print fill it out and fax or email back to us ASAP

1110 Arthur Avenue

Rockford, IL 61101​

(815)668-8699

MuslimFuneralHomeRockford@gmail.com

© 2018 by ICNA Rockford