Application for
Pioneer Certificate
Scott County
, Kansas
  Name of Pioneer (as it will appear on certificate)


  date of birth __________________    place of birth __________________________

  date of marriage _______________   place of marriage _______________________

  date of death _________________     place of death __________________________

  spouse’s name ________________________________________________________
  earliest date in Scott County _____________________________________________

   Line of descendant:  please fill in as many names as necessary to show generations

  from pioneer to the descendant named on Certificate. Add a page, if needed.

 2.  Their child :  ______________________________________________________
    date of birth ____________________  place of birth _______________________

    spouse ‘s name _____________________________________________________

 3.  Their child: _______________________________________________________

  date of birth  _____________________  place of birth _______________________

  date of marriage  _________________  place of marriage ____________________
  date of death  ____________________  place of death _______________________
  spouse’s name _______________________________________________________

 4. Their child:  _______________________________________________________

   date of birth _____________________  place of birth _______________________

   date of marriage __________________  place of marriage ___________________

   date of death _____________________  place of death ______________________

   spouse’s name ______________________________________________________

 I certify that the statements made in this application are true, to the best of my
 knowledge.  I understand that the application and its attachments become the property
 of Scott County Genealogical Society, and may be used for any lawful purpose,
 including display, reproduction, or publication.

Name of descendant (as it will appear on certificate) _____________________________  

  Signature of APPLICANT ___________________________________ date ________
      street/post office box   _________________________________________________

      town  and zip code ____________________________________________________         

      email address, if available _________________________________

    You may purchase the certificate for a person who is not related to you.  

    (Documented evidence should accompany the application. Each person (including
  the applicant) on the lineage chart should be proved as the child of the
  preceding generation. Do not send original documents. Please submit copies only,
  as all applications and verifying material will become the property of the  
  Scott County Genealogical Society.  Please, write the generation number on
 each photocopy that pertains to that generation.
 For instance, if a newspaper clipping mentions generation #2, write 2 on that  copy.
 If the clipping also shows generation #1, also write 1 on the same copy.

     To prove that my ancestor was in Scott County, Kansas, and that I
   descend from this ancestor, I am including the following documentations :

  Generation 1.

  Generation 2.

  Generation 3.

  Generation 4.

  Generation 5.

  Generation 6.

  Generation 7.

Please attach another sheet, if necessary.

Examples of sources of proof
(SEND COPIES ONLY – items will not be returned):
Include dates of newspapers, etc.

  census records                  obituaries
  county histories                 birth, marriage, death records
  newspaper clippings         baptism, church records
  land records                    plat maps, with owners listed
  military records               tombstone inscriptions –give location of cemetery
  military records              estate records
  school papers                family letters or diaries
  voter registration            city directories
  immigration                    naturalization

   You may submit additional information about the pioneer ancestor if you wish.  
   Consider including a short narrative of the highlights of their life in Scott County,   
   Kansas.  A COPY of the pioneer’s photograph would enhance the application.
 Note: If you are unsure of any dates or information, please use a question mark  (?)  .

 Please include the maiden names of all females and full names of all, if known.

 If your source of information is from  a publication that can’t be sent, please include the                
 title, volume, page, location of repository (library, archives, etc), or other information  
 to document each generation.        

 The submitter does not have to be a resident of Scott County, Kansas.

This application will use about 4 pages when printed.

  Fees for each certificate are $10.00.  Checks can be made out to
  Scott County Genealogical Society and mailed with the application.
  For questions and mailing address, please email:

  Scott County Genealogical Society

  *please do not write below this line. Thank you*

   Application received date: ___________________

   Certificate mailed date: _____________________

   Certificate number  ________________

   Approved by pioneer committee member _________________________________