Muslim Funeral Home In Northern Virginia
Janazah Services Office: 703-263-1683 Mobile: 571-490-2249 Fax: 1-866-315-0682
Death Certificate Form
DECEDENTS LEGAL NAME (First, Middle, Last)
Date of Death
Date Of Birth
EVER IN US ARMED FORCES?
Branch OF Military ( WHERE APPLICABLE)
Place of Death
Name of Hospital or Place of Death
Full street address of place of death, including zip code
Full street address of decedents residence Include the zipcode.
Name of Decedent's Father (if unknown, write unknown)
Mother's Name (Her birth name or legal name before married)
Race of deceased
Other (must describe below)
Describe "Other" race (mixed races, rare races, etc) for Example: ARAB, KURDISH, BERBER, PUNJABI, TRINI, Etc.
Level of Education
12 (High School)
Citizen of what Country?
Birthplace, City and State or City and Country
Marital Status (at time of death)
Married but Seperated
Spouse's Name (if widowed write the name of the spouse who already died) (if divorced, write Divorced)
Social Security Number, if none, write NONE
Last Job or Career, and Type of Industry (Do not write retired DO NOT LEAVE BLANK)
Informant's Name (who is filling out this form?)
Informant's relationship to deceased
Informant's Mailing Address
Place of Disposition (Cemetery name and address)
Cause of death (for informational purposes only)
Doctor Name, Address and Phone Number (please give this information to the best of your ability)
Your email address
Your phone number
ADDRESS WHERE DEATH CERTIFICATE IS TO BE MAILED:
Notes or special instructions:
How many copies of the death certificate are needed? (please calculate one for each bank account, mortgage company, life insurance, credit card, embassy, if there is property back home)
Typically Virginia Death Certificates are issued to the address provided within about 2 weeks. For Maryland and DC deaths, please allow the certificate turnaround time to be extended to 3-4 weeks.
I have read the above statement.
Thank you for contacting us. We will get back to you as soon as possible
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