Name of applicant as will appear on certificate
Address
City, State, Zip


Name of Pioneer to appear on certificate
Date and place of birth
Date and place of marriage
Date and place of death
Date and location of Pioneer Settlement in Hart County, Kentucky
Pioneer's mother's name
Pioneer's father's name
Pioneer's spouse's name
Spouse's date and place of Birth
Spouse's date and place of Death
Spouse's mother's name
Spouse's father's name

Children of Pioneer

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

name
born, where
died, where
married, date

list additional children on seperate sheet

Ancestor Chart
Generation 1: name of settler

Generation 2: their child was my
born place
married place
died place
spouse

Generation 3: their child was my
born place
married place
died place
spouse

Generation 4: their child was my
born place
married place
died place
spouse

Generation 5: their child was my
born place
married place
died place
spouse