HENRY COUNTY GENEALOGICAL SOCIETY
PIONEER OF HENRY COUNTY ILLINOIS CERTIFICATE APPLICATION
| APPLICANT:__________________________________________________________________________________________________ ADDRESS:____________________________________________________________________________________________________ CITY:____________________________________________________________STATE:__________ZIP:_______________________ PHONE:_______________________________________________ e-mail: _______________________________________________ |
PIONEER ANCESTOR:____________________________________________________________________________________________________________
DATE PIONEER CAME TO HENRY COUNTY, ILLINOIS:__________________________________________________________________________________
DATE OF BIRTH:_____________________________PLACE OF BIRTH:______________________________________________________________________
DATE OF DEATH:_________________________PLACE
OF DEATH:________________________________________________________________________
PLACE BURIED:_______________________________________________________________________________________________________________
DATE OF MARRIAGE:________________________PLACE OF MARRIAGE:____________________________________________________________
PIONEER'S SPOUSE'S NAME:_____________________________________________________________________________________________________
SPOUSE'S DATE OF BIRTH:__________________ SPOUSE'S PLACE OF BIRTH:_________________________________________________________________
SPOUSE'S DATE OF DEATH_________________: SPOUSE'S PLACE OF DEATH:_________________________________________________________________
PLACE WHERE BURIED:______________________________________________________________________________________________________________
PIONEER'S FATHER'S NAME:___________________________________________________________________________________________________________
PIONEER'S MOTHER'S NAME:__________________________________________________________________________________________________________
CHILDREN OF ANCESTOR
NAME BORN WHERE DIED WHERE SPOUSE
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________________
SIGNATURE:______________________________________________________________ DATE:______________
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