Pioneer Ancestor
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Parents (Mother's maiden name, if known)
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Parents' marriage date?
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Pioneer's Occupation (s)
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Education
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Religious Affiliation
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Military Service
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Immigration (date & place of entry, if known)
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Naturalization (date & place, if known)
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Other items of interest concerning pioneer (previous marriages, membership in clubs or organizations, political or church activities, distinguishing physical characteristics, etc.)
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Children of Pioneer:
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| Name Date & Place of Birth Date of Death Date of Marriage Spouse |
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(Applicant's signature) (date)
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