Applicant's Name
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Address
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Name of descendant (as it is to appear on the certificate-please print clearly)
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Pioneer Ancestor
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(first) (middle) (maiden) (surname)
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Date & Place of Birth
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Date & Place of Marriage
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Date & Place of Death
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Pioneer Spouse
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(first) (middle) (maiden) (surname)
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Date & Place of Birth
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Date & Place of Marriage
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Date & Place of Death
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Pioneer ancestor first settled in County in 18
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Previous known residences
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To the best of my knowledge, the above information and all other information submitted becomes the property of the Will/Grundy Counties (IL) Genealogical Society, and I give permission to the Society to use this material in any publications or for other purposes the Society deems suitable.
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(Applicant's signature) (date)
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