Disclaimer
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Al Falah Center provides Funeral assistance as a FREE service to the community. All payments collected are paid to external entities. Al Falah Center does not make a profit in the process of providing the service.
By submitting this form, you authorize Al Falah Center and the Funeral Home contracted by Al Falah Center to secure the body of the deceased mentioned below for funeral services.
This is a binding contract, after submission of this form, if you decide to proceed with another service, you will be liable to pay the costs incurred, these costs will be payable to the Funeral Home and/or Cemetery depending on the time invested by them, it could be between $300 to $600.
Condition 1
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Al Falah Center provides Funeral assistance as a FREE service to the community. All payments collected are paid to external entities. Al Falah Center does not make a profit in the process of providing the service.
By submitting this form, you authorize Al Falah Center and the Funeral Home contracted by Al Falah Center to secure the body of the deceased mentioned below for funeral services.
This is a binding contract, after submission of this form, if you decide to proceed with another service, you will be liable to pay the costs incurred, these costs will be payable to the Funeral Home and/or Cemetery depending on the time invested by them, it could be between $300 to $600.
Condition 2
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When you utilize services from Al Falah Center for burial, you "DO NOT" become owner of the land where the grave is situated. You agree that you will abide by all rules and regulations of the cemetery
Note: Construction of a boundary, wall, permanent monuments etc. is not allowed in any cemetery without proper written authorization from the cemetery
Funeral Services Needed for
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First name of the deceased
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Middle name of the deceased
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Last name of the deceased
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Date of birth
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MM
DD
YYYY
Date of death
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MM
DD
YYYY
SSN Number
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Where is the body?
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Name Of Hospital/Nursing Home/Medical Examiner's Office
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Street Address Of Pick Up Location
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City of pick-up location
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State of Pick-up location
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ZIP code of pick-up location
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If Deceased Was In Hospice Care, Provide Name Of The Nurse
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Provide Contact Number Of The Nurse
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(###)
###
####
Street address of the deceased
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City Of Deceased
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State Of Deceased
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ZIP code of the deceased
City Of Birth
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State/Province Of Birth
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Country Of Birth
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Ethnicity
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Describe other ethnicity
Education Level
Describe other educational level
Most Recent Employer
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Address Of Most Recent Employer
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Most Recent Job Title
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Father's First Name
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Father's Last Name
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Mother's First Name
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Mother's Last Name Before Marriage (Maiden Name)
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Marital Status of the deceased
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Spouse First Name
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Spouse Last Name
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List Name Of All Children
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List Name Of All Siblings
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Does The Family Own A Plot (Grave) For Burial
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If Family Owns A Plot (Grave) For Burial, Provide Name Of Cemetery
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If Family Does Not Own A Plot (Grave) For Burial, Provide Name Of Cemetery Where You Prefer The Burial
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Will Family Members Participate In Washing & Shrouding (Maximum 4 Members Allowed)
Will Someone From The Family Lead Salat-Al-Janazah
Has The Family Received Information Of Cost Of Funeral (Payments Must Be Made Before Salat-Al-Janazah)
Was The Deceased Covered By MEDICAID?
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Do you want to process MEDICAID Reimbursement?
How Many Death Certificates Do You Need?
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Informant First Name
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Informant Last Name
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Informant Relation To The Deceased
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Informant Street Address
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Informant City
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Informant State
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Informant Zip
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Informant Mobile Number
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(###)
###
####
Informant Email
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