Place in 1 and | 



pedigree/ name ) 



1. Date of birth. Birthplace. 



2. Occupation. Residences. 



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



marriage, j Total J deceased. J 



4. ditto of ) Naof "idaus. No.ofdaus. ) 



spouse / deceased. j 



ages 



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 o. 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. 

 $. Graver illnesses 



( in middle age. 



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



17. General remarks. 



35. 



