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