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100th Birthday
Name:
*
Maiden name:
Current address:
City:
State:
Zip:
Date of birth (mm/dd/yyyy):
*
+
Place of birth (city/state):
How long have you lived in Kenosha?:
Education:
If married, place of marriage:
Date of marriage (mm/dd/yyyy):
+
Spouse's name:
If deceased, date of death:
+
Family:
Children
Grandchildren
Great-
grandchildren
Great-great-
grandchildren
Number of:
Children
Grandchildren
Great-
grandchildren
Great-great-
grandchildren
Children's names:
Name
Current city/state
Age
Child 1
Name
Current city/state
Age
Child 2
Name
Current city/state
Age
Child 3
Name
Current city/state
Age
Child 4
Name
Current city/state
Age
Child 5
Name
Current city/state
Age
Child 6
Name
Current city/state
Age
Child 7
Name
Current city/state
Age
Child 8
Name
Current city/state
Age
Former occupation and employer:
0/500 characters
Community activities:
0/500 characters
Memberships, achievements/awards:
0/500 characters
Comment on changes in the world that have impressed you in your century of life:
0/1000 characters
Submitted by:
*
Phone number:
*
Submitter's email address:
*
Confirm email address:
*
You may wish to include a photo with your submission. Photos should be in a standard format (.jpg, .gif) and 2 mb or smaller in size.
Photograph
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