APPLICATION FOR CALIFORNIA PIONEER CERTIFICATE
 
If you qualify for a Pioneer Certificate (you can document your ancestor's arrival in California prior to May 10, 1869), please print this form, fill it in, and send to Root Cellar with your appropriate fee ($5 for members, $10 for non-members), along with this requested verification material.
Root Cellar - Sacramento Genealogical Society, PO Box 265, Citrus Heights, CA  95611-0265
 
Please fill in the blanks clearly and legibly:

Name of Applicant: ____________________________________

Street Address: ________________________________

City: _______________________State: ______Zip: ____________

Phone: _________________Email:_______________

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: ______________________________