ICN Funeral Services Registration Form

Funeral and Cemetery Service

Registration Form
Purpose: This registration form is to initiate and document ICN burial services for the deceased. Please make sure to visit our website www.icntn.org/funeral for details on the burial process, prices, and policy. The information gathered in this form will be used to create the death certificate, so please ensure it is correct.

Instructions:
- Click "Next" to continue completing the following form. You will be asked to "Review Answers" before "Submit" to complete.
- Items marked with an asterisk (*) require a response.
- You can save your responses to complete later by clicking on "Save for Later".
- Before beginning the form make sure to gather information about the deceased (birth date, SSN, etc.), parent information, and the ID of the deceased individual. This form will take approximately 10-15 minutes to complete.
- The authorized representative listed should have superior right to complete the funeral arrangements for the deceased. The mailing address of the authorized representative is where the completed death certificate will be mailed.
Have questions? Email funeral@icntn.org, call or text 615-200-0755, or message us on WhatsApp.

Disposition (Office Use Only)
Funeral & Cemetery Services Representative Name*
Funeral & Cemetery Representative Signature*

Clear
Date Information Verified and Approved*

MonthDayYear
Date
List any special conditions which should be included in the funeral contract for goods and services

Authorized Representative Information (Next of Kin/Family or Power of Attorney)
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Mailing Address*

Street Address and Apartment/Suite Number

Apartment Number, if applicable

CityState

Zip Code
Relation to Deceased*
Did the deceased have a Will, Trust, Preneed, or Power of Attorney?*
Upload a copy of the legal document(s)*

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(Will, Trust, Preneed, Power of Attorney, etc.)
Cancelof
Is this person also the billing contact?*

Billing Contact Information
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Mailing Address*

Street Address

Apartment Number, if applicable

CityState

Zip CodeCountry
Relation to the Deceased*

SpouseSon/DaughterParentGrandparentAunt/UncleCousinNephew/NieceOther

Family Information
Father's Name*

First NameMiddle NameLast Name
Mother's Name*

First NameMiddle NameMaiden Name
Surviving Spouse*

First NameSurname

Other Details
Would you like an email to be sent to the ICN community about the passing of this individual?*
Salaatul-Janazah Preference Location*
Special Note (optional)

Funeral Package
Funeral Package Prices

All prices subject to change without notice

Balance must be paid in full before service begins
- Standard Package: $3,500 includes:
  - Funeral Coach & Supervision for Services
  - Transportation of the deceased within 25 mile radius (to funeral home and cemetary)
  - Islamic & Sanitary Care for your Loved One (Ghusl - Body Washing and KAFFAN)
  - Burial Plot & Grave Preparation
  - Filing of Death Certificate
- Child 2 & Under: $3,000 includes:
  - Everything in "Standard Package". This package is only for unborn child (120 days) - 2 years of age.
- Optional Headstone: $700 includes:
  - 24" x 12" Headstone engraved with name of the deceased, birth date, date of death, and plot number. This headstone is available for selection with either package. If no headstone is selected, only a plot number sign will be placed in front of the grave.
Select the Desired Funeral Package for Your Loved One:*

Standard: $3,500Standard w/Headstone: $4,200Child Under 2: $3,000Child Under 2 w/Headstone: $3,700
Method of Payment*

Pay Now by Card or PayPalPay by Check or Cash at Office
Card or PayPal Payment Amount
Check or Cash Payment Amount
ICN Zakat Assistance Program

Families unable to pay a portion of funeral & cemetary services may apply, through our office, for Zakat assistance (not available for optional headstone). Please note the following regarding the Zakat assistance policy:
- Individuals and families needing zakat assistance must complete the online form and attach all required supporting documentation before any assistance can be granted. Applicant may be required to present additional supporting documents.
- Assistance is provided based on each individual/families assessment of "need".
- $500 is the maximum a family can receive in zakat assistance in a 12-month period. Any amount over that requires zakat committee approval.
List the amount of Zakat assistance needed below, if any:
*This amount of assistance is not guaranteed and is subject to approval from the zakat committee. Any portion not approved must be paid by the family before any services begin*

Attestation and Payment
Please carefully read the following before signing

The rules, conditions and procedure of burial are established by The Islamic Center of Nashville - Funeral and Cemetery Services (“ICN ''), which are set according to the Holy Quran and Sunnah of the Prophet (PBUH.).

The Rules, conditions and procedures of burial are as follows:
1. The burial procedure must be led by ICN’s Imam and funeral representatives.
2. The deceased shall be from the residence of the Greater Nashville Area.
3. No casket or any form of boxes shall be used to bury the deceased.
4. Any kinds of fences, walls, columns, are not permitted around or on the graves.
5. Pictures, statues are not permitted.
6. Headstones are allowed, but no higher than 2 feet above the ground.
7. The deceased shall be buried eight (8’) feet deep with an impermeable plastic bag.
8. Total amount due is to be paid before burial services begin.
*Do not do anything to the graves without prior approval of the funeral committee.
Authorization and Attestation - by signing below, you are attesting to the following:*

I (we) the representative(s) hereby confirm that all of the above is true to the best of my knowledge and testify that the deceased mentioned herein is a Muslim.I (we) the representative(s) are not aware of any person who has a superior right to complete the funeral arrangements, or anyone who objects to my arranging for the disposition of the deceased mentioned herein. I (we) are not aware of any written legal instructions (Will, Trust) by the decedent, or any contract for funeral services by the decedent, that gives direction or control of the disposition of the decedent’s remains to any other person or facility.I (we) the representative(s) accept all the rules and regulations imposed on the Islamic Center of Nashville by the Zoning office in Davidson County.I (we) the representative(s) agree to abide by any rules, conditions and procedures set forth in this agreement and accept any future updates for the operation of the Graveyard established by ICN.I (we) the representative(s) agree to pay ICN a fine for violating any of these rules, conditions and procedure.I (we) the representative(s) grant ICN and it's delegates permission to perform the necessary tasks in burying the deceased mentioned herein.
Decedent Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Amount Due Now
Remaining Balance Due
Card/PayPal Payment Due Now
prevnext( X )
USDDescription

Should be Empty:

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Funeral and Cemetery Service