Place in 1 

 pedigree / 



and ) 

 name j 



1. Date of birth. 



2. Occupation. 



Birthplace. 



Residences. 



3- Age 



;e at ) 

 arriage. j 



} 



4. ditto of 

 spouse 



r sons 



Total 



No. of-> , 



1 daus. 



No. of sons ) 

 deceased. / 



No. of daus. 1 

 deceased, j 



ages 



ages 



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. 



j2. Character and 

 temperament. 



13. Favorite pursuits 

 and interests. 

 Artistic aptitudes. 



14. Minor ailments to i in youth, 

 which there was •' 

 special liability ( in middle age. 



itli. 



f in yout 

 15. Graver illnesses. ■' 



( in middle age. 



1 6. Cause and date of death, and age at death. 



17. General remarks. 



33 



