Cooroy-Noosa Genealogical & Historical
Research Group Inc.
Application for 'Descendants of Pioneers'
Certificate
Please print or type all entries and allow
4-6 weeks for processing
________________________________________________________________________________
Name of Applicant ____________________________________________________
Address _____________________________________________________________
City/Town ____________________________________________
Postcode ______
State _______________________________________________________________
________________________________________________________________________________
Name of Recipient (Please enter name exactly
as it should appear on the certificate)
___________________________________________________________________________________________
Address______________________________________________________________
City/Town_____________________________________________
Postcode _______
State ________________________________________________________________
________________________________________________________________________________
To whom is the certificate to be mailed Applicant
Recipient
________________________________________________________________________________
Name of Pioneer (Please enter name exactly
as it should appear on the certificate)
___________________________________________________________________________________________
Please complete as much of the following
information as possible.
All dates should be in the form dd-mmm-yyyy
(eg. 01-Feb-1894)
Date of Birth ________________ Place __________________________________
Date of Death __________________ Place __________________________________
Date of Marriage _______________ Place __________________________________
Place of Burial _________________________________________________________
Date of arrival in the Cooroy-Noosa District
__________________________________
________________________________________________________________________________
Information required in the pedigree chart
to be attached to application
Name of Recipient
Names of Recipient's Parents (and dates of
birth if known)
Names of Recipients Grandparents (and dates
of birth if known)
Name of Pioneer (and date of birth if known)
Proof (List all documents submitted to prove
descent - attach additional sheet)
Do NOT submit original documents - photocopies
only please
I give permission for the submitted documents
to be retained by the Group for Historical
Research purposes. Yes/No Signed
.
Please mail this completed form with attachments
and payment to
Pioneer Certificate Application
Cooroy-Noosa Genealogical & Historical
Research Group Inc.
PO Box 792, Cooroy, Queensland. 4563
Email: info@genealogy-noosa.org.au