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Blank No. 6 Series II. Form B. 3.

[?] - Your Maternal Grandfather: home in city or country? Country (?)

1 - age when married? ---

2 - occupations? Student

3 - health? Delicate.

4 - number of children? one. b.) number reaching maturity? one.

[2?] - Your maternal grandmother: home in city or country? Country or village.

1 - age when married? ---

2 - occupations? ---

3 - health? Fairly good.

4 - age and cause of death? ---

III - Your husband: nationality, if American[underlined], of what descent?

1 - date of birth? 1859, Oct 16.

2 - early life in city or country? Country.

3 - height? 5 ft 9 in.

4 - weight? 156 lb.

5 - muscular or weak? Muscular.

6 - Where educated? degrees if any? A. B. Ripon College, Ph.D., J. H. U.

7 - If a college man, has he been athletic? no.

8 - Complexion? dark.

9 - Temperament? Sangine

10 - Does he use tobacco? No, not habitually.

11 - Occupations? Teacher.

12. Health? Excellent.

13 Diseases in his family: nervous disorders?[underlined] Rheumatism?
Sporadi[s?]ease
Consumption?[underlined] Dyspepsia? Varicose viens? Heart Disease?
Hernia? Habitual Constipatio? Catarrh?

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