SHELBY COUNTY HISTORICAL SOCIETY, INC.
1854 Old Courthouse
P.O. Box 457 ~ Columbiana, Alabama 35051

SHELBY COUNTY ALABAMA
PIONEER CERTIFICATE PROGRAM APPLICATION
This "application form" may be printed and submitted as shown. Please type or print information plainly.

APPLICANT WILL QUALIFY FOR THE FOLLOWING CERTIFICATE (CHECK ONLY ONE):
(1)  _____ Pioneer Certificate ... 1830 or earlier.
(2)
  _____ Settler Certificate ... 1831 through 1860.
(3)
  _____ Early Resident Certificate ... 1861 through 1900.

EARLIEST YEAR ANCESTOR LIVED IN SHELBY COUNTY ALABAMA: ____________
[Please attach copy of documentation of "Proof of Earliest Year" ancestor lived in Shelby County Alabama]

CERTIFICATE FEE: $20.00 for each submission

Please contact  Bobby Joe Seales  with questions concerning this form.

APPLICATION DATE: ______________________________________________

APPLICANT: ______________________________________________________________
                  Name as it will appear on certificate
           ______________________________________________________________
               Mailing Address
           ______________________________________________________________
               City                                                 State          Zip 
TELEPHONE  _____________________________________________________

E-MAIL  ________________________________________________________


NAME OF ANCESTOR  _______________________________________________________
        Date of Birth:  ______________________   Place: ______________________
        Date of Death:  ______________________   Place: ______________________
        Date of Marriage:  ___________________   Place: ______________________
        SPOUSE:  ________________________________________________________
                   (if female give maiden name, if known)

        Date of Birth:  ______________________   Place: ______________________
        Date of Death:  ______________________   Place: ______________________


List "SOURCES OF PROOF OF DIRECT DESCENT" for each generation. [Please number "Proof of Direct Descent" to correspond to each generation number.]

1.  _________________________________________________________________ 2.  _________________________________________________________________ 3.  _________________________________________________________________ 4.  _________________________________________________________________ 5.  _________________________________________________________________ 6.  _________________________________________________________________ 7.  _________________________________________________________________ 8.  _________________________________________________________________

LINE OF DIRECT DESCENT CHART

1.  _______________________________   was born on   __________________________
        Applicant                                              Day        Month        Year
    _______________________________      ___________________________
        County                               State
    _______________________________________________
        Spouse (if female, give maiden name)

2.  Child of _________________________ Spouse  _______________________________
    Born ________________________ Place  ____________________________
    Married  ____________________ Place  ____________________________
    Died  _______________________ Place  ____________________________

3.  Child of _________________________ Spouse  _______________________________
    Born ________________________ Place  ____________________________
    Married  ____________________ Place  ____________________________
    Died  _______________________ Place  ____________________________

4.  Child of_________________________ Spouse  _______________________________
    Born ________________________ Place  ____________________________
    Married  ____________________ Place  ____________________________
    Died  _______________________ Place  ____________________________

5.  Child of _________________________ Spouse  _______________________________
    Born ________________________ Place  ____________________________
    Married  ____________________ Place  ____________________________
    Died  _______________________ Place  ____________________________

6.  Child of _________________________ Spouse  _______________________________
    Born ________________________ Place  ____________________________
    Married  ____________________ Place  ____________________________
    Died  _______________________ Place  ____________________________

7.  Child of _________________________ Spouse  _______________________________
    Born ________________________ Place  ____________________________
    Married  ____________________ Place  ____________________________
    Died  _______________________ Place  ____________________________

8.  Child of _________________________ Spouse  _______________________________
    Born ________________________ Place  ____________________________
    Married  ____________________ Place  ____________________________
    Died  _______________________ Place  ____________________________

This application and documentation will be filed in the archives of the Shelby County Museum and Archives
to help preserve the history of your ancestor and will be made available for public research.

Please mail (1) this "Pioneer Certificate Program Application" with copy of documentation of
"Proof of Earliest Year" ancestor lived in Shelby County Alabama
 (2) Copy of documentation of "Proof of Direct Descent" for each generation  (3) and $20.00 certificate fee to

SHELBY COUNTY PIONEER CERTIFICATE PROGRAM
Shelby County Historical Society, Inc. ~ P.O. Box 457 ~ Columbiana, Alabama 35051

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