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Blank No. 3 Series II. Form B. 2.

(continued) 4 - Number of children? 8 number reaching maturity? 7

Your Paternal Grandmother: home in city or country?

1 - age when married? 18

2 - occupations? Care of house.

3 - health? Good.

4 - Age and cause of death? 80 - Weakness of old
age. paralysis.

Your Mother: 1 - Nationality, if American of what descent? English.

2 - home in city or country before marriage? Country.

b) home in city or country after marriage? City.

3 - Occupations before her marriage? Teaching.

b) after her marriage? Housekeeping Family Cares.

4 - Note any prenatal influences before your birth.

5 - her health previous to your birth? Fairly good.

b - after your birth? As good as could be expected
when constantly overworked.

6 - Number of miscarriages? One.

7 - Her age if living and present health? if not, age at time
of death and cause? 56. Consumption:

8 - how was your mother's health affected by the climacteric
(change of life).

9 - name any diseases in her family. Consumption.