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

V - Your Maternal Grandfather: home in city or country? Country.

1 - age when married? 28

2 - occupations? Drayman. Farmer.

3 - health? Good.

4 - number of children? 10 b) number reaching maturity? 6

VI - Your maternal grandmother: home in city or country? Country.

1 - age when married?

2 - occupations? Care of family.

3 - health? Good.

4 - age and cause of death? 48. Immediate cause. Measles -
with cold which caused quick consumption.

VII - Your husband: nationality, if American, of what descent? English.

1 - date of birth? 1864

2 - early life in city or country? Country

3 - height? 5 feet - 10 3/4 inches.

4 - weight? 160

5 - muscular or weak? muscular.

6 - Where educated? degrees if any? Cornell. C.E.

7 - If a college man has he been athletic? Not especially

8 - Complexion? Dark.

9 - Temperament?

10 - doe he use tobacco? Not habitually

11 - occupations? Teaching.

12 - health? Excellent.

13 dieseases in his family: nervous disorders? Rheumatism?
consumption? Dyspepsia? Varicose veins? Heart Disease?
Hernia? Habitual Constipation? Catarrh?

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