Name of submitter
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Address
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Name of person to whom certificate is to be issued:(This should be the last person on the lineage chart.)
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Generation 1. Pioneer Ancestor
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Generation 2. Name
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Birth Date & Place
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Marriage Date & Place
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Death Date & Place
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Spouse
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(if female, full maiden name)
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Generation 3. Name
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Birth Date & Place
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Marriage Date & Place
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Death Date & Place
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Spouse
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(if female, full maiden name)
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Generation 4. Name
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Birth Date & Place
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Marriage Date & Place
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Death Date & Place
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Spouse
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(if female, full maiden name)
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| Proof must be submitted showing descent from one generation to the next. |
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(Applicant's signature) (date)
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