Registration Form

Joan Musgrove

Holly Harrington

Eulalio Cabriales

Alfonso Diaz

Maria Jauregui Gonzalez

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Perez Family Funeral Home
1347 Del Norte Road
Camarillo, CA 93010
805-484-6365

Registration Form

Registration is free with our funeral home. We will keep your wishes at our funeral home for when yours our your loved one's time arrives.

I am planning for:
Personal Information
Name:
Email Address:
Address:
City:
State/Province:
Country::
Zip Code:
Phone Number:
Place of Birth:
Date of Birth:
Sex:
Citizenship:
Marital Status:
Spouse (Maiden Name):
Father's Name:
Mother's Maiden Name:
SSN:
Religous Preference:
Education
High School Name:
# of Years:
College Name:
Family Information: Please list the names of survivors and state their relationship to you, their spouse's names and the city in which they live as you wish to have them listed in the memorial. (The following is a guide to assist you.) SURVIVORS: Spouse, Sons, Daughters, Parents, Brothers, Sisters, Grandchildren, (Great-grandchildren), Grandparents, Others (Eg. Son: Joe Smith and his wife Paula of Milledgeville)
Survivors:
Preceded in Death by::
Additional Information and Organ:
Work History
Occupation:
Business:
Industry:
Company:
Number of Years:
Years Retired:
Military Service
Service Branch:
Serial Number:
Date Enlisted:
Rank at Discharge:
Date Discharged:
Discharge on File At:
Combat Action:
Funeral Preferences
I prefer my Funeral Service to be
Public:
Private:
Visitation
Public:
Private:
Place of Service:
Other:
I prefer
Cremation:
Burial:
Entombment:

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