Funeral Home Use Request

Funeral Home MUST complete this form each time the Preparation oom is used

Note For Funeral Home:

1. Obtain authorization prior to using the facility (Verbal Authorization Accepted)

2. Remove all items that are left over after washing and shrouding of the deceased and carry out with you. Do not leave any items in the Masjid dumpster as Masjid is not equipped to discard Bio-Hazard materials. (Example of items included but not limited to Wash cloths, Paper towels, Aprons, Body bag, Disposable gloves, Clothing and accessories of the deceased etc.)

3. Bring in all necessary supplies for washing, shrouding, cleaning, disinfecting and sanitizing.

4. Thoroughly clean and sanitize the Stainless Steel washing and shrouding table (Use a disinfectant and sanitizer)

5. Thoroughly clean and sanitize the utility sink (Use a disinfectant and sanitizer)

6. Thoroughly clean, mop and dry the Preparation Room Floor (Use a disinfectant and sanitizer)

7. Donate generously to cover Masjid Expenses.

Funeral Home Information

Funeral Home Name

Attendant Name

First Name

Last Name

Business Phone

(###)

###

####

Mobile Number

(###)

###

####

Date of Facility Usage

YYYY

Authorized By

Deceased Person Information

Name

First Name

Last Name

Gender

Male

Female

Date of Death

YYYY

Date of Burial

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Cemetery

Next of Kin Information

Name

First Name

Last Name

Relationship to Deceased

Home Phone

(###)

###

####

Mobile Phone

(###)

###

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