Eugenics as a Creed and the Last Decade of Galtoris Life 295 



Register 



Initials 



Notable achievements of any brother or sister of the Father of the Applicant 

 that fall within the purview of this Certificate 



We certify that to the best of our knowledge the above account is correct, also that with 

 the exceptions mentioned below, no member of this Fraternity has ever suffered from Insanity, 

 Epilepsy or other severe form of nervous disease. 



Exceptions giving full particulars. If no 

 exceptions write the word "None" 



Signatures of 



Writer of the above notice. 

 The Applicant. 



QUESTIONS C, CONCERNING THE KINDRED OF THE APPLICANT. 



On the Fraternity consisting of the Mother of the Applicant and of the Mother's whole 

 brothers and sisters. Write M by the side of the figure in the first column that refers to the 

 Mother, and describe her achievements more fully than those of her sisters. 



We certify that to the best of our knowledge the above account is correct, also that with the 

 exceptions mentioned below, no member of this Fraternity has ever suffered from Insanity, 

 Epilepsy or other severe form of nervous disease. 



Exceptions giving full particulars. If no 

 exceptions write the word " None " 



Signatures of 



( Writer of the above notice. 

 \2'he Applicant. 



