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Page 15 The Islamic Bulletin Issue 18
THIS INFORMATION IS REQUIRED FOR THE DEATH CERTIFICATE:
Full Name ___________________________________________________
Date Of Birth __________________________Place Of Birth____________
Social Security Number _______________________________________ Race
Street Address And Zip ________________________________________
City/Town Of Residence ________________ County Of Residence_______
Full Name Of Father________________________________________
First And Maiden Name Of Mother
Highest Level Of Education In Years
Elementary/Secondary (0-12) _______________ College (1-4 Or 5+)_____________________________
Marital Status (Circle): Never Married Married Widowed Divorced
If Married Or Widowed, Name Of Spouse _______________________________________________
Usual Or Last Occupation ___________ Kind Of Business Or Industry __________________________
Name Of Attending Physician_________________________________________________________
Next of Kin and Contact info:
THENETVALUEOF YOURESTATE
I, ASSETS (Add up what you own and where located)
A, PersonalProperty:
1.Cash ___________________________________Located: _________________________________________
Cash_______________________________________Located: _________________________________________
2.Savings: _____________________________________ Bank_________________________________
Savings: __________________________________________________ Bank_________________________________
3.Checking: _______________________________ Bank _______________________________________
4.Other: ____________________________________________________________
5.Interest in Profit Sharing, Stock, Partnership, etc._____________________________________________
6.Automobiles, Jewelry, Household & Clothing____________________________________________
7.Miscellaneous________________________________________________________________
B, Real Estate (describe for each property you own)
Value_________________________________________________________Located___________________________________
Value_________________________________________________________Located__________________________________
Total Value of all the above assets:
II, LABILITIES (add what you owe)
1. _____________________________________________ Money Owed to _________________ $
Address and Phone:________________________________________________________________________
2. _____________________________________________ Money Owed to________________ $
Address and Phone:________________________________________________________________________
3. _________________________________________________________________________ Mortgage
4. ___________________________________________________________________________
5. Personal debts: (loans, car, etc.) ________________________________________________________
Total Amount owed :_________________________________________________________________
Safe Deposit Box__________________________located at______________________________
Passport # &Type ____________________________ Important Passwords #: __________________________
This document, comprising ________pages, is made in _______ copies. The original is with me, one copy is
deposited with _______________________________ Name and Phone # ___________________________and
onecopywith__________________________________ Name and Phone #
WITNESSES
On this day,______________________________ date of____________________________________________ ,
the undersigned declared to us that this instrument was his/her Will and requested us to act as witnesses to it.
He/She thereupon signed this Will in our presence, all of us being present at the same time. We now, at his/her
request, in his/her presence, and in the presence of each other, subscribe our names as witness and declare that
we understand this to be his/her Last Will, and that, to the best of our knowledge the testator is of the age of
majority, or is otherwise legally empowered to make a Will, and under no constraint or undue influence.
Witness 1.________
Name and Signature
Witness 2.________
Name and Signature
HEALTHCARE PROXYAND LIVINGWILL
If the time comes when I am incapacitated and can no longer actively take part in decisions for my own life and am unable to direct my
physician as to my own medical care, I wish this statement to stand as a testament of my wishes.
I,_____________________________________________________________________________________________________________________________hereby appoint the
following individual as my health care agent.
Name: Phone#
Address:
This health care proxy shall take effect if and when I become unable to make my own health care decisions. In respect of each decision
made for me by my agent, it is my wish and direction that my agent be guided solely by Islamic Shariah as to what my own decision
would have been in the same circumstances. Without limiting the unrestricted scope of my agent’s authority hereunder, I expressly
authorize my agent to direct that no treatment be conducted or withheld from me if to do so is against the teachings of Islam, to the best
of understanding of my agent. I direct that medication be judiciously administered to me to alleviate pain. I do not intend any direct
taking of my life. I also direct that "life support systems" may be used in a judicious manner and its use discontinued, just like any other
medicine, if it becomes reasonably apparent that it has no curative value. The "life support systems" include but are not limited to
artificial respiration, cardiopulmonary resuscitation, artificial means of providing nutrition and hydration, and any pharmaceutical drugs. I
direct that my family, all physicians, hospitals and other health care providers and any court or judge honor the decision of my
agent/alternate agent. This request is made, after careful reflection, while I am of sound mind.
Name:___________________________________________ Signature:
Witness1.
Name and Signature
Witness2.
Name and Signature
***OPTIONAL***
Subscribed and sworn to before me this________________________day of _____________,
NotaryPublic__________________________________________________________________________________________ Signature & Seal
In Case of Emergency Contact: (Include Mosques and all phone numbers)
We hope this will benefit you and your family. For a will to be legal in most states, you have to be at least 18
years old and of sound mind. The will must be signed by you and witnessed by two people who won't receive
anything from your estate. However, please consult with an Islamic Scholar and/ or an attorney first. As always,
please feel free to pass or share this information on to your friends and other Muslims. Pray for the people at
The Islamic Bulletin who prepared this sample Will for you. Jazakum Allahu Khairan (May Allah Reward You).
If more copies are needed please go to: and click on enter here and then Islamic Last
Will. For a list of mosques click mosques under enter here. You can print the whole mosques in a PDF format.
Rev. 2009
For More Information Please Contact: The Islamic Bulletin
P.O. Box 410186 Web:
San Francisco, CA 94141-0186 E-Mail: