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Blank No. 5 Series II. Form B. 3.

I - Your Maternal Grandfather: home in city or country? -

1 - age when married? -

2 - occupations? farmer & teacher

3 - health? - [deleted]died suddenly[deleted] Died suddenly at 64

4 - Number of children? 11 b) Number reaching maturity? 11

II - Your maternal grandmother: home in city or country? -

1 - age when married? -

2 - occupations? -

3 - health? good

4 - age and cause of death? died suddenly [deleted]at [??][deleted] 81

III - Your husband: Nationality, if American, of what descent? French descent

1 - date of birth? 26 Oct. 1855

2 - early life in city or country?

3 - height? 6 - 3 1/2

4 - weight? 250

5 - muscular or weak?

6 - Where educated? degrees if any?

7 - If a college man, has he been athletic?

8 - Complexion?

9 - does he use tobacco?

11 - occupations?

12 - health? good, but has catarrah.

13 - diseases in his family: Nervous Disorders? Rheumatism?
Consumption? Dyspepsia? Varicose veins? Heart Disease?
Hernia? Habitual Constipation? Catarrh?

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