FATHER'S MOTHER 



I. Date of birth. 



Birthplace. 

 Residences. 



2. Occupation. 



.} 



3- Age at 

 marriage, 



4. ditto of ) 

 husband / 



sons 



Total 

 No. o{\ 



daus. 



No. of sons 

 deceased. 



No. of daus. 

 deceased. 



ages 

 ages 



5. Mode of life so far as 

 affecting growth or health. 



6. Was early hfe 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 

 ot below the average. 



JO. Keenness or imperfection 

 of sight or other senses. 



II. 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 v^as ' 

 special liability ( in middle age. 



15. Graver illnesses < 



( in youth. 



( in middle age. 

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



17. General remarks. 



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