PATHEK'S FATHER'S MOTHER 



1. Date of birth. 



2. Occupation. 



Birthplace and origin. 

 Residences. 



3- Age at 

 marriage, 



4. ditto of ) 

 husband J 



:. I Total ( 



No. of^ 



ons ) 



daus. 



No. of sons 

 deceased, 



No. of daus. 

 deceased. 



ages 

 ages 



5. Mode of life so far as 

 aflecting growth or health. 



6. Was early life laborious ? why and how ? 



7. Adult height. 



Colour of hair when adult. 



Colour of eyes. 



S. General appearance. 



9. Bodily strength and 



energy, if much above 

 or below the average. 



10. Keenness or imperfection 

 of sight or other senses. 



II. Mental powers and 

 energy, if much above 

 or below the average. 



12. Character and 

 temperament. 



13. Favorite pursuits 

 and interests. 

 Artistic aptitudes. 



14. Minor ailments to j in youth, 

 which there was ^ 

 special liability ( in middle age. 



15. Graver illnesses 



( in youtK 



( in middle age. 

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



17. General remarks. 



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