Place in ) and I 



pedigree / name j 



1. Date of birth. Birthplace. 



2. Occupation. Residences. 



3- Age at ) / sons No. of sons 1 



marriage, j Total J deceased. J 



4. ditto of ) Naof &quot;jdaus. No. ofdaus. I 



spouse / deceased, j 



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 &quot;below the average. 



10. Keenness or imperfection 



of sight or other senses. 



1 1 . Mental powers and 



energy, if much above 

 or below the average. 



r 2. Character and 

 temperament. 



13. Favorite pursuits 



and interests. 

 Artistic aptitudes. 



14. Minor ailments to tin youth, 

 which there was -| 

 special liability ( in middle age. 



( in youth. 

 15. Graver illnesses 



{ in middle age. 



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



17. General remarks. 



F 33 



