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  Blue Hills Genealogical Society Barron County, Inc
 PIONEER/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, typically held in October.

 

                                             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 grants the Blue Hills Genealogical Society-Barron County, Inc. permission to publish genealogical data contained herein and my name and contact information in a printed or online index, and to release copies of the application to genealogical researchers.

Applicant's Signature __________________________________________________________________

                                                                                    (TO PAGE 2)



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