MOTHEB 3 



1. Date of birth. Birthplace. 



2. Occupation. Residences. 



3. Age at 1 A sons No.of sons ) ^ 

 marriage. J Total ] deceased. j 



4. ditto of 1 ^°- °*^"i daus. No. of daus. i_ 



husband / ' 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 adulL Colour of eyes. 



8. General appearance. 



9. Bodily strength and 



energ5% if much above 

 or below the average. 



10. Keenness or imperfection 



of sight or other senses. 



11. 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 ^ 



special liability ( in middle age. 



( in youth. 



15. Graver illnesses -j 



( in middle age. 



16. Cause and date of death, and age at death. 



17. General remarks. 



19 



