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Pioneer Certificate Application Form
Name of Pioneer Ancestor:
Born: *Where:
Died: *Where:
Cemetery and Location:
Date Married: *Where:
Pioneer's Spouse (maiden name):
Born: *Where:
Died: *Where:
Cemetery and Location:
Date Pioneer settled in 
Chicago/Cook County:
Name of Pioneer's Father:
Name of Pioneer's Mother:
*Where=     City/ Town/Township,    County,   State/Country
Children of Pioneer Ancestor     (Use separate sheet if needed):
First Name Born Where Died Where
To the best of my knowledge, the above information is correct. I understand that all material submitted
becomes the property of the Chicago Genealogical Society, and hereby give my permission to publish.
this material
Name of Applicant:
Phone#: E-mail address:
Signature: Date:
This page was updated 04/15/04.
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