APPLICATION FOR PIONEER, COUNTY AND CENTURY CERTIFICATE

Please check one:

___ Pioneer Certificate (Settled in Carver County 1854 or before)

___ County Certificate (Settled in Carver County 1855 - 1865)

___ Century Certificate (Settled in Carver County at least 100 years prior to date of the application)

NAME OF APPLICANT (as it is to appear on the Certificate)

I understand that submission of this application grants the Carver County Historical Society permission to publish genealogical data contained herein and my name and contact information in a printed or online index, and to release copies of the application to genealogical researchers.

Applicant’s Signature

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Address, City, State, and Zip ________________________________________________

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NAME OF CARVER COUNTY ANCESTOR (as it is to appear on the Certificate)

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Carver County Township where Ancestor first settled or was born___________________

Timeframe in Carver County ____________________ - __________________________

Date of Birth_____________________________________________________________

Place of Birth ____________________________________________________________

Name of Ancestor’s Father _________________________________________________

Name of Ancestor’s Mother_________________________________________________

Ancestor’s Date of Marriage ________________________________________________

Location of Marriage ______________________________________________________

Date of Death____________________________________________________________

Burial Location___________________________________________________________

NAME OF ANCESTOR’S SPOUSE _________________________________________

Spouse Date of Birth _____________________________________________________

Spouse Place of Birth_____________________________________________________

Name of Spouse’s Father__________________________________________________

Name of Spouse’s Mother _________________________________________________

ANCESTOR’S CHILDREN

Child’s Name Date/Place of Birth Date of Death/Burial Location Spouse’s Name/Maiden Name Date/Place of Marriage

1._______________________________________________________________________________________________________________________________

2._______________________________________________________________________________________________________________________________

3._______________________________________________________________________________________________________________________________

4._______________________________________________________________________________________________________________________________

5._______________________________________________________________________________________________________________________________

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9._______________________________________________________________________________________________________________________________ 10._____________________________________________________________________________________________________________________________