PIONEER CERTIFICATE APPLICATION
___ Allegan County ___ Cass County ___ Berrien County
___ Kalamazoo County ____ Van Buren County
(please check one)
Application should be filled in as accurately as possible in black ink or typed.
Please capitalize all surnames. Do not use numbers only for dates (6-2-97
should be June 2, 1997 or 2 June 1997). Attach proofs in generation order
(beginning with Generation #1 as applicant) to the back of application and
mail with check or money order for $10.00 to:
VBRGS - Pioneer Certificate Project, P.O. Box 143, Decatur, MI 49045.
Applicant: _______________________________________________________________________________
Address: _________________________________________________________________________________
City: _____________________________________________________ State: ________ Zip: _______
Name as should appear on certificate: ____________________________________________________
Additional certificates for children or parents of applicant may be obtained for
an additional $3.00 each. Name(s) for additional certificates as they should
appear:
______________________________________________
______________________________________________
______________________________________________
______________________________________________
Pioneer Ancestor:
Name: __________________________________________________________________________________
Date and place of earliest residence: __________________________________________________
Proof of early residence: ______________________________________________________________
Birth date and place: ___________________________________________________________________
Death date and place: __________________________________________________________________
Spouse: _________________________________________________________________________________
Marriage date and place: ________________________________________________________________
Other spouses: __________________________________________________________________________
Spouse birth date and place: ____________________________________________________________
Spouse's parents: ______________________________________________________________________
Military Service: ______________________________________________________________________
From where did ancestor emigrate: _______________________________________________________
_____________________________ When: ____________________________________________________
I understand that the information enclosed on this application and the attached
proofs will become the property of the Van Buren Regional Genealogical
Society and will be made available for future researchers. I also understand
that the $10.00 fee is non-fundable and that my application is subject to the
approval of the Pioneer Certificate Committee.
Signature: ____________________________________________ Date: ___________________________
***************************************************************************************
VBRGS Use Only:
Ancestor: __________________________ Applicant: _______________________________________
Date Received: ______________________ File Number: _____________________________________
Date Returned for additional information/corrections: ___________________________________
__________________________________________________________________________________________
Date Approved: ______________________ Approved By: _____________________________________
Memo: ___________________________________________________________________________________
__________________________________________________________________________________________
LINEAGE
Fill in blanks as accurately as possible in black ink or typed. Please enter
dates in format (July 6, 1997 or 6 Jul 1997). Enter places city/village
/township, county, state/country. Surnames should be in all CAPS.
1. Applicant: ___________________________________________________________________________
Born: _____________________________ Place: ____________________________________
Residence: ___________________________________________________________________
Spouse: ____________________________ Marriage: ________________________________
Place: _______________________________________________________________________
2. Child of: ____________________________ and ___________________________________
Born: ____________________________ Born: ________________________________
Married: ______________________________________________________________________
Died: ___________________________ Died: _____________________________________
3. Child of: ____________________________ and _________________________________
Born: ____________________________ Born: _________________________________
Married: ________________________________________________________________________
Died: ____________________________ Died: __________________________________
4. Child of: ____________________________ and _________________________________
Born: ____________________________ Born: __________________________________
Married: ________________________________________________________________________
Died: ___________________________ Died: _________________________
5. Child of: ____________________________ and _________________________________
Born: ____________________________ Born: __________________________________
Married: ________________________________________________________________________
Died: ____________________________ Died: ___________________________________
6. Child of: ____________________________ and _________________________________
Born: ____________________________ Born: ___________________________________
Married: ________________________________________________________________________
Died: ____________________________ Died: ___________________________________
7. Child of: ____________________________ and _________________________________
Born: ____________________________ Born: ___________________________________
Married: ______________________________________________________________
Died: ____________________________ Died: __________________________________
8. Pioneer Ancestor: ___________________________________________________
Children: __________________________ Born: _____________________
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________
Please list proofs by generation beginning with generation #1 (label proofs with
generation #)
1. ___________________________________________________________________________________
2. ___________________________________________________________________________________
3. ___________________________________________________________________________________
4. ___________________________________________________________________________________
5. ___________________________________________________________________________________
6. ___________________________________________________________________________________
7. ___________________________________________________________________________________
8. ___________________________________________________________________________________