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Carnegie Institution of Washington 



Department of Experimental Evolution 



Cold Spring Harbor, N. Y. 



AND 



EUGENICS RECORD OFFICE 



COLD SPRING HARBOR, LONG ISLAND, N. Y. 



Please don't write here. 



No 



Sent 



Returned 



Ack'd 



Collab 





FOURTH EDITION 



N. B. Fill out Name and Address 



Name of person responsible for filling this blank 



Date.... Permanent Address 



Town and State. 



It is requested that the person who receives this schedule should take it home and fill it out in consultation 

 with his parents, if living, and with other, especially older, members of the family. 



When filled out, return this schedule to the undersigned. 



In filling out the schedule you have to decide on your own place in the pedigree — father, mother, child, etc., 

 make entry for yourself and then assign your relatives to corresponding places in the schedule. 



A duplicate blank schedule will be sent on request to those that wish to retain a copy of their record. 



The information asked for is to be used in a study of human heredity. It is expressly announced that all 

 information received will be held as confidential and no names published. 



C. B. DAVENPORT, 



Cold Spring Harbor, N. Y. 



E.R.O. 2-' 16, loM. 



