MOTHER'S FATHER 



1. Date of birth. Birthplace. 



2. Occupation. Residences. 



3. Age at ) The place for this entry 



marriage. J is at 4 in next page. 



, r -r ] The place for this entry 



4. do. of wife > ■ \ ■ .. 



^ J IS at 3 in next page 



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. 



10. Keenness or imperfection 

 of sitrht or other senses. 



1 1 . 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 fin youth, 

 which there was -^ 

 special liability ( in middle age. 



( in youtk 

 15. Graver illnesses -' 



{ in middle age. 



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



17. General remarks. 



22 



