Name of Applicant: ____________________________________
Street Address: ________________________________
City: _______________________State: ______Zip: ____________
Ancestor’s name as you want it placed on the certificate: _________________________________
Name (Yours or that of the certificate recipient) to be inserted:
Where in California did your ancestor settle before May 10, 1869?
Township: _____________________County:__________________Date: ___________________
Ancestor’s Birth Date:______________ Place:___________________________
Ancestor’s Death Date: _____________ Place:___________________________
Ancestor’s Burial Place: _________________________________________
Ancestor’s Spouse: ______________________________
Date of Marriage: _____________ Place: _________________
Spouse’s Birth Date:_______________ Place:___________________________
Spouse’s Death Date: ______________ Place: ___________________________
Spouse’s Burial Place: __________________________________________
After the certificate has been awarded, do you want your birth, death and marriage certificate copies returned to you? Yes( ) No( ) If they are not returned to you they will be shredded.
Do you wish to be contacted by other researchers in regard to your Pioneer? Yes( ) No( )
I understand that this information may be used for publication by Root Cellar - Sacramento Genealogical Society, in Root Cellar PRESERVES, and I hereby release said Society from any claims by me under the present or future “Privacy Rights” legislation/acts.
Date: ______________ Signature: ______________________________