FATHER'S MOTHER'S MOTHER : 11 



1. Date of birth. 



2. Occupation. 



Birthplace and origin. 

 Residences. 



ages 



ages 



13. Favorite pursuits 

 and interests. 

 Artistic aptitudes. 



14. Minor ailments to ( in youth, 

 which there was -^ 

 special liability ( in middle age. 



15. Graver illnesses 



( in youth. 



( in middle age. 

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



1 7. General remarks. 



27 



