Death Certificate Form

عظم الله أجركم، وأحسن عزاءكم، وغفر لميتكم
{إِنَّا لِلَّهِ وَإِنَّا إِلَيْهِ رَاجِعُونَ}

Dear Community Members Aslamo Alykom Wa Rahmatullah Wa Barakatuo

On behalf of the Mustafa Center Funeral Home team, we extend our sincerest condolences for the loss of your loved one. During this difficult time, we want to make the administrative process as simplistic as possible for your family.

One of the first steps we’ll take care of on your behalf is preparing and filing the death certificate.

J. Whitney Keiller is our Funeral Director & Manager that will manage you through this process with care and patience.

Here’s what you should know:

We traditionally give you 3 copies but if you need more than put the total number requested on the form.

Certified copies of the death certificate are important for taking care of your loved one’s affairs — things like notifying the bank, handling life insurance, managing retirement accounts, settling the estate, transferring a car title, or dealing with real estate. Today, some companies will make a copy from your original others will want an original.

Please note that the certificate is issued by the state where your loved one passed away, regardless of where they lived.

Timing. You can generally expect to receive the certified copies within about 7 business days after the certificate has been filed.

Every question on this form is listed on the death certificate , please complete the form in its entirety.

If we have follow up questions our Funeral Director will contact you for completion.

If you have general questions or want to speak to Whitney Keiller , Funeral Director contact the funeral home number

703-400-7605 .

We are honored that you have entrusted us to care for your loved one.

May Allah grant you Sabr.

Full Name of Deceased:

First NameLast Name

WOMEN (name at birth ) Maiden Name Of Deceased if married or widowed:

Social Security Number:

Date of Birth:

Date of Death

Race (White, Black, Asian, Other Specify)

Hispanic Origin (Y/N & Country):

Address of deceased

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Deceased Gender

Place of Birth (city & state or country if not USA ):

Citizen of what Country:

Full Father's Name:

Full Mother's Name:

Mother's Maiden Name:

Highest Education Completed

Profession of Deceased (before retirement)

Kind of Business or Industry:

Marital Status:

Spouse's Name if Married or Widowed, if applicable:

Veterans Status & Branch:

Bring DD 214 (discharge papers) if applicable.

Cemetery to be buried. If out of Country please include full address. Local cemetery enter just the name .

How many death certificates do you want? We typically provide 3 however you may get additional copies if needed (VA $12 , DC $18 , MD $25 each)

Informant - Who should be listed on the death certificate:

Relationship to Deceased:

Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

Email:

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signature

Informational Purposes- The funeral director will lead this process. In most cases, it needs to be signed by a physician, who will also indicate the cause of death. The certificate then goes to the health department for registration and recording. The cost of death certificates are charged by the state and is a separate charge from the funeral home charges however the funeral home will add to their contract and collect the monies. This fee is called a cash advance fee.