FATHER. 



I. Full name 2. Date of birth 



fa. Birthplace: Town State or Country 



4. Education - Favorite studies 



5. Residences, principal : 



6. Age at marriage Total No. of sons 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. 



10. Surgical operations undergone ". 



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



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



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



MOTHER. 



I. Full maiden name 2. Date of birth 



3. Birthplace: Town State or Country 



4. Education Favorite studies 



5. Residences, principal 



6. Date of marriage Place of Marriage Total No. of sons of 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 



10. 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. 



