I, (Applicant's name as it will appear on Certificate) __________________________________________,
certify that I am a descendant of (Ancestor's name) __________________________________________,
who resided in Lawrence County, Tennessee between the time period of 1817-1850 __ or 1851-1900 __. (Check appropriate time period)

Gen. 1: I am the child of (father) _____________________________
Date born:
Place born:
Date married:
Place married:
(mother)_____________________________________ (mother's info below)
Date died:
Place died:

Gen. 2: The child of (father) ________________________________
Date born:
Place born:
Date married:
Place married:
(mother)_______________________________________ (mother's info below)
Date died:
Place died:

Gen. 3: The child of (father) _______________________________
Date born:
Place born:
Date married:
Place married:
(mother)_______________________________________ (mother's info below)
Date died:
Place died:

Gen. 4: The child of (father) ________________________________
Date born:
Place born:
Date married:
Place married:
(mother)_______________________________________ (mother's info below)
Date died:
Place died:

Gen. 5: The child of (father) _________________________________
Date born:
Place born:
Date married:
Place married:
(mother)_______________________________________ (mother's info below)
Date died:
Place died:

Gen. 6: The child of (father) __________________________________
Date born:
Place born:
Date married:
Place married:
(mother)_______________________________________ (mother's info below)
Date died:
Place died:

Gen. 7: The child of (father) _________________________________
Date born:
Place born:
Date married:
Place married:
(mother)_______________________________________ (mother's info below)
Date died:
Place died:

Attach Additional Sheets If Necessary

I, the undersigned, ___ do or___ do not give permission to the Lawrence County Genealogical Society to publish my lineage, herewith submitted, in either their Lawrence County Heritage journal or a book on First Families of Lawrence County, TN. (Any material used will always have its source sited.)

___________________________________________
Typed or Printed Name of Applicant for Certificate

__________________
Date of Application

____________________________________________
Signature of Applicant

____________________________________________
Street Address City/State/Zip

____________________________________________
email address

_____________________________________________
Web Page URL

Send completed application and $10.00 check to:
Lawrence County Genealogical Society, 2588 Highway 43 S, Leoma, TN 38468

Return to the Lawrence Co. Genealogical Society Page