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
Age
Date of Birth

MonthDayYear
Date
Birthplace
Sex
Place of Death
Hispanic
Veteran Status
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
Mother's Place of Birth
Father's Name of Deceased
Father's Maiden Name
Father Still Living
Father's Place of Birth
Informant Name
Informant Relationship to Deceased
Informant Address
Informant Phone Number
Format: (000) 000-0000.
Submitter Email
example@example.com
Should be Empty: