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Blank No. 13 Series II. Form B. 4.

III. Yourself: 1. - date of birth? 1863
2 - Early life in [deleted]city or[deleted] country?
3 - height? 5. 1 1/2
4 - weight 125 --- 2 years ago
5 - complexion? not blonde, brown eyes and brown hair.
6 - temperament? fly in 40000 pieces in a minute.
7 - where educated, give [deleted]degrees if any?[deleted] in Canada Misleys[?] Methodist
College Music
8 - occupations before marriage? a) in city [deleted]or country[deleted]? b) time
spent in each? Taught music (Washington D.C.) 4 years
9 - diseases in your family? from father or mother's side?
Nervous Disorders? Rheumatism? Consumption? Dyspepsia? [in margin]Mother who [?] was small[in margin]
Varicose Veins? Heart Disese? Hernia? Habitual Constipation?
Catarrh?
10 - General health before marriage? good b) since marriage?
Paralysis? Brain Fever? Chronic Headache? Nervous Prostation?
Catarrh? Hernia? Dispepsia? Habitual Constipation? Inflammation
of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting
Blood? Consumption? Laryngitis? Tonsilitis? Insomnia?
Rheumatism? Pneumonia? Jaundice? Varicose veins?
a) Congestion of Liver
b)

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