MERCY MUSLIM CEMETERY

Acknowledgement Form

I ____________________________________________ have read the M.M.C. Rules and Regulations.

(Please print full name)

I understand and will abide by all rules and regulations.

Signed: ______________________________ Date: _______________________________

Relation to the Deceased: ____________________________________________________

Deceased’s Full Name: __________________________________________________

Date of Birth: ______________________________

Date of Death: _____________________________

Male/Female: _____________________________