MOTHER'S FATHER. 



I. Full name 2. Date of birth 



3. Birthplace: Town :.State or Country 



4. Education Favorite studies 



5. Residences, principal 



6. Age at marriage Total No. of sons of daughters Ages of those that died early, sons daughters. 



7. Occupations at successive ages 



8. Lesser diseases to which 



there was special liability : In youth In middle age. 



9. Grave illnesses in youth in middle age 



[o. Surgical operations undergone 



[I. If dead, cause of death and age at death 



tia. State whether blood relative of wife, and if so, what 



[2. Special tastes, gifts or peculiarities of mind or body. Character, favorite pursuits, etc 



MOTHER'S MOTHER. 



Full maiden name 2. Date of birth 



Birthplace: Town State or Country 



Education Favorite studies 



Residences, principal 



Date of marriage Place of marriage Total No. of sons of daughters.. 



Occupations at successive ages 



Lesser diseases to which 



there was special liability : In youth In middle age. 



9. Grave illnesses in youth in middle age 



ID. Surgical operations undergone 



11. If dead, cause of death and age at death 



12. Special tastes, gifts or peculiarities of mind or body. Character, favorite pursuits, etc 



