Intake Form

Intake Form for Decedent

Funeral Request Intake Form

This form must be completed for the deceased in order to initiate any funeral service request with Al Firdous Funeral Services.
Please fill out the Funeral Inquiry Form in its entirety, along with the Authorization Form.

If you have any questions or need assistance completing the forms, please contact us at 866-347-9262 or email al-firdous@icrva.org.

*Disclaimer the information provided is secured & will be submitted to funeral home staff to initiate the funeral process.

Vital Statistics of Deceased

Decedent's Name

First Name

Last Name

Date of Death

Time of Death

County of Death

Place of Death *

Others Specify

Facility Name

Physician Attended Name

Facility Address

Date of Birth

SSN

Gender *

Born in USA? *

State

Birth Country

US Citizen *

Country Of Citizenship

Served in Military *

Branch

Height

Weight

Race/Ethnicity

Decedent's Highest Level of Education

Decedent's Occupation

Occupation Industry

Usual Residence of the Decedent

City

State/Province

Zip/Postal

Family Details of Decedent

Marital Status *

Spouse Full Name

Father Name

First Name

Last Name

Mother Name

First Name

Last Name

Next of Kin's Name

First Name

Last Name

Relationship to Decedent

Phone Number

Janazah and Burial Information

No. of Family Member participating in Ghusl

Masjid for Janazah Prayer

Cemetery for Burial (Name and Address)

Consent

I Affirm the above information of the Decedent is correct.

I acknowledge that I have selected funeral services which implement the Washing, Shrouding, Janaza salat and Burial based on Sunni Islamic practices only.

Print Full Name

If you are human, leave this field blank.

Funeral Request Intake Form

Vital Statistics of Deceased

Family Details of Decedent

Janazah and Burial Information

Consent

We love our families, we would like to hear from you about your needs and concerns. We will do our best to fulfill them.