INSTRUCTIONS: Fill in appropriate sections on this page. Provide photocopies of documents 
for your ancestral and/or collateral lines and the Ascent and Documentation form. If your 
ancestor was the soldier's sibling, include any style family group sheet 
which shows the soldier, his parents, and his brothers and sisters. If you descend 
from more than one soldier or his/her collateral line, copy these forms and submit 
each entry separately. Please type, or handprint all information with  black ink. 
Do not highlight information on documents. 
Click here to Honor-a-Soldier.

I am applying for a Certificate as a Descendant of a soldier (or his sibling)
who served in the (check one) 
___43rd Regiment IL Vols   ___22nd Regiment IL Vols   
___who lived in St. Clair County when he mustered into the ______________Regiment
___who lived in St. Clair County at some other time during his life	




Applicant’s Name as it is to be shown on the Certificate
	___________________________________________________________________________
	                                                     
Spouse 	___________________________ (if applicable)
Address	___________________________________________________________________
City    	_______________________	State _________	9-digit Zip __________–________

I agree that this application and all documents tendered with it become the property of the 
St. Clair County Historical Society and may be stored, preserved, and published as outlined 
in the paragraph titled Disposition of Applications and Documentation.
Date: ___________________	Signature: _________________________________________


  I am a member of the St. Clair County	I am not a member, but please send me 
					membership information
  Genealogical Society   _______ (year)	Genealogical Society   _______ 
  Historical Society     _______ (year)	Historical Society     _______ 

Society Use Only

Date Received_________	Amount Paid__________	

Certificate No. Issued  _________    Date_________	Certificate Mailed Date __________


MAIL your check or money order for $35.00,** this application, ALL 
documentation (photocopies, not originals) to: SCCHS–Koerner Fund, 701 East Washington Street, 
Belleville, Illinois 62220  **$25.00 will be donated to the Gustave Koerner House Preservation