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*

MonthDayYear
Date
Funeral Director Initials
Name of Deceased*
Maiden Name
Marital Status*

MarriedWidowedDivorcedNever Married
Age*
Date of Birth*

MonthDayYear
Date
Birthplace*
Sex*

MF
Place of Death*

HospitalNursing HomeResidence
Hispanic

YN
Veteran Status

YN
Race
SSN*
Occupation
Industry
Education Level
Spouse Name
Spouse Maiden Name
Address*

Address

Street Address Line 2

City/TownState

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

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

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