| Member (full name): |
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| Date and place of birth: |
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| Present address: |
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| City: |
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| State, Zip: |
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| Profession or occupation: |
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| Connection with offices held or special duties performed in any public work or office;
church society, or social, benevolent, patriotic, political, or fraternal organization: |
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| Military services, offices and honors: |
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| Titles and dates of publication of books, pamphlets, or other literary works of which
you are the author (members are requested to give to the Reading Room a copy of all
their historical and genealogical works): |
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| References to printed works containing personal biography and ancestral history: |
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| Spouse (full name): |
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| Date and place of birth: |
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| Date and place of marriage: |
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| Date and place of death: |
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| Her (or his) Father's full name: |
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| Her (or his) Mother's full name: |
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| Biographical information concerning her (his) parents; place of residence; Father's
occupation or profession: |
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| Member's Children: |
| Name and place and date of birth/marrige/death: |
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| Name and place and date of birth/marrige/death: |
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| Name and place and date of birth/marrige/death: |
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| Name and place and date of birth/marrige/death: |
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| (Use additional sheets if necessary.) |
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| Member's Father (full name): |
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| Date and place of birth: |
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| Date and place of marriage: |
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| Date and place of death: |
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| Son of: |
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| Give the names and dates of your father's paternal ancestors in direct line as far as you
can (use additional sheets if necessary): |
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| Member's Mother (full name): |
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| Date and place of birth: |
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| Date and place of marriage: |
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| Date and place of death: |
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| Daughter of: |
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| Give the names and dates of your mother's paternal ancestors in direct line as far as you
can (use additional sheets if necessary): |
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| Signature of member: |
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| Date and place: |
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