Was there a miner in your family?

Please note: Fields marked with * are required.

Miner’s First Name * (Required)

Miner’s Middle Name

Miner's LastName * (Required)

Confirm Miner’s Last Name (Please retype) * (Required)

Miner's Picture (Must be smaller than 1MB in size)

Place of Miner’s Birth

Miner’s Country

Arrived in USA

Miner Information

Place & Manner of Miner's Death

Died

Birth Date

Married

Page 2

Place Miner Was Married

Wife's Name

Wife's Middle Name

Wife's Last Name

Place of Wife's Birth

Wife's Country

Arrived in USA

Place & Manner of Wife's Death

Died

Birth Date

Page 3

Number of Children

Child Name 1

Child's Middle Name

Child's Last Name

Birth Date

Child Name 2

Child's Middle Name

Child's Last Name

Birth Date

Child Name 3

Child's Middle Name

Child's Last Name

Birth Date

Child Name 4

Child's Middle Name

Child's Last Name

Birth Date

Child Name 5

Child's Middle Name

Child's Last Name

Birth Date

Child Name 6

Child's Middle Name

Child's Last Name

Birth Date

Child Name 7

Child's Middle Name

Child's Last Name

Birth Date

Child Name 8

Child's Middle Name

Child's Last Name

Birth Date

Child Name 9

Child's Middle Name

Child's Last Name

Birth Date

Child Name 10

Child's Middle Name

Child's Last Name

Birth Date

Page 4

Author's First Name * (Required)

Middle Name

Last Name * (Required)

Phone Number

Relationship to Miner

Street Address * (Required)

City/Town * (Required)

State * (Required)

Zip * (Required)

Are you a human? * (Required) For security purposes, please answer the following question: 1 + 1 = ?

Was there a miner in your family?

Was there a Miner in your Family?

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