Place in \ 

 pedigree j 



and 

 name 



1. Date of birth. 



2. Occupation. 



Birthplace. 

 Residences. 



5. Mode of life so far as 

 aftecting growth or health. 



6. Was early life laborious ? wliy and how ? 



7. Adult height. 



Colour of hair when adult. 



Colour of eyes. 



8. General appearance. 



g. Bodily strength and 

 energy, if much above 

 or below the average. 



1 o. Keenness or imperfection 

 of sight or other senses. 



1 1 . 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 ( in youth, 

 which there was -^ 

 special liability ( in middle age. 



15. Graver illnesses 



( in youtli. 



( in middle age. 

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



47. General remarks. 



.38 



