12 MOTHER S FATHER S FATHER 



1. Date of birth. Birthplace and origin. 



2. Occupation. Residences. 



3. Age at ) The place for this entry 



marriage, j is at 4 in next page. 



, . f ) The place for this entry 



4- do. of wife} i s a t 3 in next page 



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. 



i o. Keenness or imperfection 

 of sight or other senses. 



n. Mental powers and 

 energy, if much above 

 or below the average. 



i 2. Character and 

 temperament. 



13. Favorite pursuits 



and interests. 

 Artistic aptitudes. 



14. Minor ailments to | in youth, 

 which there was -j 

 special liability ( in middle age. 



I in youth. 

 15. Graver illnesses 



( in middle age. 



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



17. General remarks. 



