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. The information gathered in this form will be used to create the death certificate, so please ensure it is accurate. Please visit our website www.icntn.org/funeral for details on the burial process, prices, and policy.

Policy Summary:
- The deceased shall be Muslim and located in the Greater Nashville Area.
- Total amount due is required before burial services begin via Card (debit or credit), Check (paper or electronic) to "ICN", PayPal, or Cash.
- Follow the instructions provided by the ICN Funeral and Graveyard Services team, regarding transportation, Ghusl (washing), Kafan (shrouding), Salat al-Janaza (congregational funeral prayer), and burial.
Instructions:
- Click "Next" to continue completing the following form. 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.
Have questions? Email funeral@icntn.org, call or text 615-200-0755, or message us on WhatsApp.

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

First NameLast Name
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
Mailing Address*

Street Address and Apartment/Suite Number

Apartment Number, if applicable

CityState

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

(Will, Trust, Preneed, Power of Attorney, etc.)
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Upload a Picture of Authorize Representative's ID*

*This is for us to verify validity of authorized representative completing the form*
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Is this person also the billing contact?*

Billing Contact Information
Name*

First NameLast Name
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
Mailing Address*

Street Address

Apartment Number, if applicable

CityState

Zip CodeCountry
Relation to the Deceased*

SpouseSon/DaughterParentGrandparentAunt/UncleCousinNephew/NieceOther
Upload a Picture of Billing Contact's ID*

*This is for us to verify validity of billing contact*
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Deceased 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 Instructions (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 cemetery)
  - Islamic & Sanitary Care for your Loved One (Ghusl - Body Washing and KAFFAN)
  - Burial Plot & Grave Preparation
  - Filing of Death Certificate
- Born Child - 2 Years Old: $3,000 includes:
  - Everything in "Standard Package". This package is only for a born child (non stillbirth) - 2 years of age.
- Stillbirth Child/Fetal Death: $1,000 includes:
  - Burial Plot & Grave Preparation only (family is responsible for ghusl and transportation to cemetery). This package is only for fetal death (stillborn child).
Select the Desired Funeral Package for Your Loved One:*

Standard Funeral Package - $3,500Child Under 2 Funeral Package - $3,000Stillbirth Child Funeral Package - $1,000
Additional Fees (if applicable)
Enter any additional fees for transportation surcharge, lengthy body storage, etc.
Additional Fee Description*
Enter description for additional fees
Method of Payment*

Pay by Card or PayPalPay by Electronic Check/ACHPay by Paper Check or Cash at Office
Card (debit or credit) or PayPal Payment Amount*
Check (paper or electronic) 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:
- The burial procedure must be led by ICN’s Imam and funeral representatives.
- The deceased shall be a resident of the Greater Nashville Area.
- No casket or any form of boxes shall be used to bury the deceased.
- Any kinds of fences, walls, columns, are not permitted around or on the graves.
- Pictures and statues are not permitted.
- Headstones are allowed, but no higher than 2 feet above the ground.
- The deceased shall be buried eight (8’) feet deep with an impermeable plastic bag.
- 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 as the authorized representative are attesting to the following:*

The authorized representative hereby confirms that all of the above is true to the best of their knowledge and that the deceased mentioned herein is a Muslim.The authorized representative is authorized to direct the disposition of the remains of the deceased as set forth in Tenn. Code Ann. § 62-5-703 or other applicable law, has not forfeited that authority under Tenn. Code Ann. § 62-5-704, and is not aware of any person who has a superior right to complete the funeral arrangements, or anyone who objects to the representative’s arranging for the disposition of the deceased mentioned herein.The authorized representative accepts all the rules and regulations imposed on the Islamic Center of Nashville by the Zoning office in Davidson County.The authorized representative agrees 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.The authorized representative agree to pay ICN a fine for violating any of these rules, conditions and procedure.The authorized representative grants ICN and its delegates permission to perform the necessary tasks in burying the deceased mentioned herein.The authorized representative grants the Islamic Center of Nashville ("ICN") permission to send the applicable credit or debit entries (and adjustment entries), electronically or by any other commercially accepted method, to my (our) account(s) indicated and to other accounts I (we) identify in the future (the “Account”). This authorizes the financial institution holding the Account to post all such entries. I agree that the ACH transactions authorized herein shall comply with all applicable U.S. Law. This authorization will be in effect until the Organization receives a written termination notice from myself and has a reasonable opportunity to act on it.
Decedent Authorized Representative Signature*

Clear
Date*

MonthDayYear
Date
Amount Due Now*
Paid by Card or PayPal
Remaining Balance Due*
Paid by ACH, Check, or Cash

Upload a picture of a voided check

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PayPal/Card Payment*

prevnext( X )
USDDescription

	Account Type	Routing Number	Account Number
Account Details

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Security Code

Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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Funeral and Cemetery Service