FATHER S FATHER S MOTHER g 



1. Date of birth. Birthplace and origin. 



2. Occupation. Residences. 



3. Age at ) ,- sons No. of sons ) 

 marriage. / Total J deceased. j 



4. ditto of ) Naof jdaus. No. ofdaus. ) 



husband f deceased. / 



5. Mode of life so far as 



affecting growth or health. 



6. Was early life laborious ? why and how ? 



7. Adult height. Colour of hair when adult Colour of eyes. 



8. General appearance. 



9. Bodily strength and 



energy, if much above 

 or below the average. 



10. Keenness or imperfection 



of sight or other senses. 



11. Mental powers and 



energy, if much above 

 or below the average. 



12. Character and 



temperament. 



13. Favorite pursuits 



and interests. 

 Artistic aptitudes. 



14. Minor ailments to ( in youth. 



which there was * 



special liability ( in middle age. 



( in youth. 



15. Graver illnesses 



( in middle age. 



1 6. Cause and date of death, and age at death. 



17. General remarks. 



