2
1. I_________________________________ was born ________________________
   at _________________________________________________________________
       City                  County                       State
2. I am the child of __________________________________________________
   born on ________________ at ________________________________________
                               City                County        State
   died on ________________ at ________________________________________
                               City                County        State
   and __________________________________ his wife
   born on _________________at ________________________________________
                               City                County         State
   died on ________________ at ________________________________________
                               City                County         State
   married on _____________ at ________________________________________
                               City                County         State

3. The said _______________________________ was the _____________________
                                                                                                              Son or Daughter
        of __________________________________________________________________________________________________________
   born on ________________ at ________________________________________
                               City                County        State
   died on ________________ at ________________________________________
                               City                County        State
   and __________________________________ his wife
   born on _________________at ________________________________________
                               City                County         State
   died on ________________ at ________________________________________
                               City                County         State
   married on _____________ at ________________________________________
                               City                County         State

4. The said _______________________________ was the _____________________________________
                                                                                                                                                   Son or Daughter
        of _______________________________________________________________________________________________________
   born on ________________ at ________________________________________
                               City                County        State
   died on ________________ at ________________________________________
                               City                County        State
   and __________________________________ his wife
   born on _________________at ________________________________________
                               City                County         State
   died on ________________ at ________________________________________
                               City                County         State
   married on _____________ at ________________________________________
                               City                County         State