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Blank no. 4 Form B.

Date. May 12, 1892.

1.Age when you married? Twenty-nine

2. General health a) before marriage fair b) after marriage fair

[deleted]3.[deleted]

3.What knowledge of sexual physiology had you before marriage? Not any.

4. Number of times married? If more than once additional blanks will be furn-
ished you to answer the following question separately in regard to each mar-
riage.

5.number of years married? Six.

6.Do you habitually sleep with your husband? Yes.

Number of conceptions?

8.number of children? State in connection with each, Date of birth, sex,,
whether healthy or not; Note any characteristic and the cause if you can give
it.