PATRON MEMBER     $25  Attached     
              PERPETUAL MEMBER  $200 Attached     
              PERPETUAL FAMILY  $250 Attached

               Ancestors of:____________________________                            +-----------------------------------------+
               Ph:_______________                ie: 01 JAN 1977                    | 8. ___________________________________  |
               __________________      Dates Format: Day Month Year                 | b: ____________ In ___________________  |
                  (Date)               +-----------------------------------------+  | m: ____________ In ___________________  |
                                       | 4. ___________________________________  |--| d: ____________ In ___________________  |
                                       | b: ____________ In ___________________  |  |                                         |
                                +------| m: ____________ In ___________________  |  +-----------------------------------------+
                                |      | d: ____________ In ___________________  |  +-----------------------------------------+
                                |      |                                         |--| 9. ___________________________________  |
                                |      +-----------------------------------------+  | b: ____________ In ___________________  |
                          +-----------------------------------------+               | m: ____________ In ___________________  |
                          | 2. ___________________________________  |               | d: ____________ In ___________________  |
                          | b: ____________ In ___________________  |               |                                         |
                      +---| m: ____________ In ___________________  |               +-----------------------------------------+
                      |   | d: ____________ In ___________________  |               +-----------------------------------------+
                      |   |                                         |               | 10. __________________________________  |
                      |   +-----------------------------------------+               |  b: ___________ In ___________________  |
                      |         |      +-----------------------------------------+  |  m: ___________ In ___________________  |
                      |         |      | 5. ____________________________________ |--|  d: ___________ In ___________________  |
                      |         |      | b: ____________ In ____________________ |  |                                         |
                      |         +------| m: ____________ In ____________________ |  +-----------------------------------------+
                      |                | d: ____________ In ____________________ |  +-----------------------------------------+
                      |                |                                         |--| 11. __________________________________  |
                      |                +-----------------------------------------+  |  b: ___________ In ___________________  |
               +-----------------------------------------+                          |  m: ___________ In ___________________  |
               | 1. ___________________________________  |                          |  d: ___________ In ___________________  |
               | b: ____________ In ___________________  |                          |                                         |
               | m: ____________ In ___________________  |                          +-----------------------------------------+
               |                                         |                          +-----------------------------------------+
               | Spouse: ______________________________  |                          | 12. __________________________________  |
               |                                         |                          |  b: ___________ In ___________________  |
               +-----------------------------------------+                          |  m: ___________ In ___________________  |
                      |                +-----------------------------------------+  |  d: ___________ In ___________________  |
                      |                | 6. ____________________________________ |--|                                         |
                      |                | b: ____________ In ____________________ |  +-----------------------------------------+
                      |         +------| m: ____________ In ____________________ |  +-----------------------------------------+
                      |         |      | d: ____________ In ____________________ |  | 13. __________________________________  |
                      |         |      |                                         |--|  b: ___________ In ___________________  |
                      |         |      +-----------------------------------------+  |  m: ___________ In ___________________  |
                      |   +-----------------------------------------+               |  d: ___________ In ___________________  |
                      |   | 3. ___________________________________  |               |                                         |
                      |   | b: ____________ In ___________________  |               +-----------------------------------------+
                      +---| m: ____________ In ___________________  |               +-----------------------------------------+
                          | d: ____________ In ___________________  |               | 14. ___________________________________ |
                          |                                         |               |  b: ___________ In ____________________ |
                          +-----------------------------------------+               |  m: ___________ In ____________________ |
                                |      +-----------------------------------------+  |  d: ___________ In ____________________ |
                                |      | 7. ____________________________________ |--|                                         |
                                |      | b: ___________ In _____________________ |  +-----------------------------------------+
                                +------| m: ___________ In _____________________ |  +-----------------------------------------+
                                       | d: ____________________________________ |  | 15. __________________________________  |
                                       |                                         |--|  b: ___________ In ___________________  |
                                       +-----------------------------------------+  |  m: ___________ In ___________________  |
               Chart No. _____                    Write Other SURNAMES Below which  |  d: ___________ In ___________________  |
               No. 1 on this chart is the same    you may want on the chart.        |                                         |
               person as No.____ on Chart No. ___                                   +-----------------------------------------+
                                                  ---------------------------------

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