HENRY COUNTY GENEALOGICAL SOCIETY
PIONEER OF HENRY COUNTY ILLINOIS CERTIFICATE APPLICATION


APPLICANT:__________________________________________________________________________________________________

ADDRESS:____________________________________________________________________________________________________

CITY:____________________________________________________________STATE:__________ZIP:_______________________

PHONE:_______________________________________________ e-mail: _______________________________________________


PIONEER ANCESTOR:
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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

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Please list additional children on a separate sheet.

PERMISSION RELEASE: Information I have submitted for the "Pioneer of Henry County Illinois Certificate" may be used by the Henry County Genealogical Society in future publications.


SIGNATURE:______________________________________________________________ DATE:______________

 

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