WIC Funeral Arrangement Form

WORCESTER ISLAMIC CENTER FUNERAL HOME INC.

248 Mountain East Street, Worcester, MA 01606
Dr. Mohammed A. Hussain, M.D., type 3 Licensed Funeral Director
Dr. Muhammad Ramzan, M.D, President and Facility Manager
Attorney Khalid Naseem, Chief Legal Counsel
Email *
example@example.com
COVID
Death is COVID related
Date of Death *

Month Day Year
Date
Funeral Director Initials
Name of Deceased *
Maiden Name
Marital Status *

Married Widowed Divorced Never Married
Age *
Date of Birth *

Month Day Year
Date
Birthplace *
Sex *

M F
Place of Death *

Hospital Nursing Home Residence
Hispanic

Y N
Veteran Status

Y N
Race
SSN *
Occupation
Industry
Education Level
Spouse Name
Spouse Maiden Name
Address *

Address

Street Address Line 2

City/Town State

Zip code
Mother's Name of Deceased *
Mother's Maiden Name
Mother Still Living *

Y N
Mother's Place of Birth *
Father's Name of Deceased *
Father's Maiden Name
Father Still Living *

Y N
Father's Place of Birth *
Informant Name *
Informant Relationship to Deceased *
Informant Address *
Informant Phone Number *
Submitter Email *
example@example.com
Should be Empty:

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