FIRST FAMILIES OF RUGBY CERTIFICATE APPLICATION
Fill in all blanks as completely as possible. Type or print all information.
A check or money order for $15 must accompany the application.

A. Applicants Name
______________________________________________________________
(as it will appear on the certificate)

______________________________________________________________
(street address)

______________________________________________________________
(city, state, zip)

B. Name of ANCESTOR __________________________________________
(name of qualifying ancestor who was an original Rugby resident, as it will appear on the certificate) 

Birth_______________________________________Death__________________________________
            (date)                          (place)                                                      (date)                         (place)
 

Baptism_____________________________________ Buried________________________________
                     (date)                           (place)                                              (date)                       (place)
 

Married___________________________________________________________________________
                       (date)                                              (place)                              (by: Rev., J. P. & name)
 

SPOUSE __________________________________________________________________________
                         (name)                                                                (maiden, when applicable)
 

Birth________________________________________Death__________________________________
             (date)                                     (place)                                            (date)                    ( place)
 

Emigrated from _____________________________________________________________________
                                   (township)                     (county)                                   (state, province/country) 

Proof of arrival date _________________________________________________________________

__________________________________________________________________________________
 
 

Fill in all blanks, beginning with yourself as #1. Type or print all information.

1. I, (name)___________________________________was born on (date)________________

    at (place) ___________________________________(county) _______________________

    (state, province/country) _____________________________________________________

    married to (spouse) _________________________________________________________

2. Child of ____________________________ married to _____________________________

    Born___________________________ place _____________________________________

    Married ________________________ place _____________________________________

    Died ___________________________place _____________________________________

3. Child of ____________________________ married to _____________________________

    Born___________________________ place _____________________________________

    Married ________________________ place _____________________________________

    Died ___________________________place _____________________________________

4. Child of ____________________________ married to _____________________________

    Born___________________________ place _____________________________________

    Married ________________________ place _____________________________________

    Died ___________________________place _____________________________________

5. Child of ____________________________ married to _____________________________

    Born___________________________ place _____________________________________

    Married ________________________ place _____________________________________

    Died ___________________________place _____________________________________

6. Child of ____________________________ married to _____________________________

    Born___________________________ place _____________________________________

    Married ________________________ place _____________________________________

    Died ___________________________place _____________________________________

7. Child of ____________________________ married to _____________________________

    Born___________________________ place _____________________________________

    Married ________________________ place _____________________________________

    Died ___________________________place _____________________________________

8. Child of ____________________________ married to _____________________________

   Born___________________________ place ______________________________________

   Married ________________________ place ______________________________________

   Died ___________________________place ______________________________________

9. Child of ____________________________ married to _____________________________

   Born___________________________ place ______________________________________

   Married ________________________ place ______________________________________

   Died ___________________________place ______________________________________
 
 
 
 

List sources of proof as to descent by generation (please number photocopied proofs to
correspond to generation numbers.

1._______________________________________________________________________________

2. ______________________________________________________________________________

3._______________________________________________________________________________

4. _______________________________________________________________________________

5. _______________________________________________________________________________

6. _______________________________________________________________________________

7. _______________________________________________________________________________

8. _______________________________________________________________________________

9. _______________________________________________________________________________

REMINDER: EACH STEP MUST BE PROVEN! Date Submitted:_______________

___________________________________________
(signature of applicant submitter)

___________________________________________
(address if different from page 1)

Mail To:
Historic Rugby
P.O. Box 8
Rugby, Tennessee 37733