MOTHER S MOTHER S MOTHER 15 



1. Date of birth. Birthplace and origin. 



2. Occupation. Residences. 



3. Age at ) , sons No. of sons 



e. / Total 



No. of 



marriage. J Total ) deceased. 



litto of ) Na ol &quot; daus. No. of daus. \ 



husband / 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. 



S. General appearance. 



9. Bodily strength and 

 energy, if much above 

 or below the average. 



10. Keenness or imperfection 

 of sight or other senses. 



ii. Mental powers and 

 energy, it much above 

 or below the average. 



12. Character and 

 temperament. 



13. Favorite pursuits 



and interests. 

 Artistic aptitudes. 



14. Minor ailments to I in youth, 

 wliich there was -j 

 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. 



