PIONEER/EARLY SETTLER/CENTURY CERTIFICATE APPLICATION

Application for:              Pioneer                    Early Settler                 Century                    Date:    

NAME OF APPLICANT:  _______________________________________________________________

Address:  ______________________________________________________________________________

City: ___________________________________             State:  ________                        Zip Code:  ______

TO WHOM IS THE CERTIFICATE TO BE ISSUED (enter name exactly as it is to appear on the Certificate)

NAME OF APPLICANT: _______________________________________________________________

Address:  _____________________________________________________________________________

City: ___________________________________           State:  ________                        Zip Code:  ______

PIONEER/EARLY SETTLER/CENTURY ANCESTOR (enter name exactly as it is to appear on the Certificate)

NAME OF ANCESTOR:  ________________________________________________________________ 

Date of Birth ______________        Place of Birth _______________________________________________ 

Date of Death _____________        Place of Death ______________________________________________ 

Date of Marriage ___________       Place of Marriage ___________________________________________ 

Place of Burial  _________________________________________________________________________ 

When did he/she settle in Juneau County, Wisconsin? _____________________________________________

Where in Juneau County, Wisconsin did he/she settle? ____________________________________________ 

SPOUSE OF ANCESTOR: ______________________________________________________________ 

Date of Birth ___________             Place of Birth _______________________________________________

Date of Death __________             Place of Death ______________________________________________ 

Did spouse accompany Pioneer/Early Settler/Century Ancestor when he/she settled in Wisconsin? _______                       

If Yes, do you want spouse named on the certificate? _____________________________________________