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  Blue Hills Genealogical Society Barron County, Inc
email:  info@bluehillsgenealogicalsociety.org
 PIONEER or CENTURY CERTIFICATE APPLICATION
 
Mail to:  Blue Hills Genealogical Society-Barron County, Inc., P.O. Box 383, Cameron, WI 54822
 on or before September 1.  Certificates are awarded at the Annual "Members Only" banquet.

 

                                             Please PRINT or TYPE all entries

Application for: Pioneer Century Certificate Date:

 

        NAME OF APPLICANT _______________________________________________________________

        Address __________________________________________
        E-mail _________________________

        City __________________________________ State _________ ZIP ___________-____________

 

        TO WHOM IS THE CERTIFICATE TO BE ISSUED? (Enter name exactly as it is to appear on the Certificate.)

                   ___________________________________________________________________________

        Address _________________________________________________________________________

        City ______________________________________ State ________ ZIP ____________-________

 

        TO WHOM IS THE CERTIFICATE TO BE ISSUED? (Enter name exactly as it is to appear on the certificate.)

                    ________________________________________________________________________________   

 

        PIONEER/CENTURY ANCESTOR (Enter name exactly as it is to appear):

                __________________________________________________________________________________

        Date of Birth ___________________ Place ______________________________________________

        Date of Death __________________ Place ______________________________________________

        Date of Marriage _______________ Place ____________________________________________

        Place of Burial ___________________________________________________________________

        When did he / she settle in Barron County, Wisconsin? ____________________________________

        Where? Township / Municipality ______________________________________________

 

        SPOUSE OF ANCESTOR: _____________________________________________________________

        Date of Birth ___________________ Place ______________________________________________

        Date of Death __________________ Place ______________________________________________

        Did spouse accompany Pioneer/Century Ancestor when he / she settled in Wisconsin? __________

        If Yes, do you want spouse named on the certificate? (Enter name exactly as it is to appear on the certificate.)

                  _________________________________________________________________________________

 


I understand that
Submission of this application, if approved,  grants the Blue Hills Genealogical Society-Barron County, Inc. permission to publish my name on genealogical data contained herein in printed indexes or online indexes, and to release copies of the application to genealogical researchers.  Unsigned applications will be returned!

           
           Applicant's Signature __________________________________________________________________
 

                                                                                    (TO Application Instructions )



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