STILLBORN Application & Consent Form

This application form gives permission to MFS to perform the Funeral of the deceased with the consent of the Next of Kin or Authorised representative.

This form MUST be completed.

ALL of the information of the deceased, including details of the family is COMPULSORY for the registration of the death with the Department of Births, Deaths and Marriages. Correct information is essential.

For any non applicable information please insert N/A on the form or if completed before death - for dates can insert todays date.

Deceased's Full Name*

PrefixFirst NameLast Name

Residential Address*

Street number

Street name

SuburbState

Postal CodeCountry

Telephone NOK*

Telephone

Date of Birth*

DayMonthYear

Date of Death*

DayMonthYear

Age at death*

Years / Months / Days

Gender*

MaleFemale

Place of Death*

Street Address

Street Address Line 2

SuburbState

Post CodeCountry

Place of birth (City, town and Country)*

Name of Hospital where stillbirth or death occurred

Contact person at the Hospital Nurse or Social worker

Telephone Number of Hospital Contact person

Was deceased of Aboriginal or Torres Strait Islander Origin*

NOYes AboriginalYes TSIBoth

Parents details*

	First name	Surname	Occupation during working life
Father's details
Mother's details

Full Name NOK*

First NameMiddle NameLast Name

Address of NOK*

Street Address

Street Address Line 2

CityState

Postal CodeCountry

Relationship to deceased*

Phone Number Next of Kin*

Mobile Number Next of Kin*

E-mail NOK*

Email address NOK

Ghusl Venue:

This is to confirm that I am the authorized next of kin or representative of the deceased, and / or I act with the full authority of the family of the deceased*

YES

I confirm that the Deceased is Muslim.*

YES

I also confirm that I am liable to pay all fees and charges due for the funeral.*

Yes

I also understand that MFS Ltd & will not be held responsible for any error or omission beyond or outside of their control.*

Yes

I do NOT hold MFS Ltd or its Directors, employees or volunteers responsible for an injury (either physical or psychological) sustained by myself or any person nominated by me, whilst observing any Islamic customs of washing the body, carrying the body, travelling in the hearse, at the grave side or entering the grave to lower the remains of the deceased into the grave.

Yes

By submitting this form I acknowledge that I understand & accept the above terms and conditions and acknowledge that the information provided is correct*

Yes

The opinion of our Imams is that, if a baby was deceased in the womb or born with no life, then there is no requirement to perform the Ghusl or janaza salah. I understand that MFS follows this practice. If I have a different request, I will communicate this to the MFS member and I will make a note of this in the comments section below.*

Yes

I understand that MFS provides services in accordance with Islamic practice and principle and will not emulate any practice or request considered to be outside of generally accepted Islamic practice. MFS will regretfully decline any such request.

YES

Date & Time form submitted*

DayMonthYearHourMinutes

I hereby give consent to MFS Ltd to make all the necessary funeral arrangements for the deceased including the local council grave booking and to complete all the necessary regulatory paperwork as required by law. The information provided above will be used.

I understand that all fees due are payable on the day of the funeral. The total fee is approximately $ 500 (Brisbane) and up to $ 2500 on weekends and after hours.

These fees consist of the local council fees & charges, and the balance is the fee charged by MFS.

The application for the Death Certificate if required for children is done by us online to the Department, and the death certificate is sent directly to you within 2-3 weeks. The application is made based on the information provided by you on this form.

MFS is a not for profit organisation, and all fees generated are utilised for the running of the organisation and its activities.

Incorrect information submitted by you on this form will result in unnecessary fees and delays.

Appropriate arrangements for the fee settlement must be discussed with MFS once the form is submitted. MFS will only proceed with the necessary bookings once this has been done.

This form, the consent to release form from the hospital or nursing home and the original local council application forms will have to be signed when you meet the MFS representative.

Comments

Please provide any additional information

Type in letters in the field as seen*

eSignature*

Clear

MUSLIM FUNERAL SERVICES Ltd (MFS)

1. Details of the Deceased

2. Parents details of deceased

3. Next of Kin of Deceased