MOTHEB'S MOTHEB 7 



1. Date of birth. Birthplace. 



2. Occupation. Residences. 



3. Age at I i sons No. of sons ) 

 marriage. J Total \ deceased. j 



4. ditto of ) , Na Of 1 



husband J 



daus. _? No. of daus. ) 

 deceased. J 



5. Mode of life so far as 

 affecting growth or health. 



6. Was early life laborious ? why and how ? 



Colour of hair when adult. Colour of eyes. 



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 , *s. 



of sight or other senses. 



u. Mental powers and 

 energy, if much above 

 or below the average. 



1 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. 



youth. 

 15. Graver illnesses 



middle age. 



( in you 

 ( in mic 



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



17. General remarks. 



