100th Birthday
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Name:
Maiden name:
Current address:
City:
State:
Zip:
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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's names:
Name
Current city/state
Age
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8
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
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Submitted by:
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Phone number:
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Submitter's email address:
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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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Indicates Response Required