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Blank No. 14 Series II. Form B. 3.

Your Maternal Grandfather: home in city or country? New town
1 - age when married?
2 - occupations? Physician
3 - health? Good.
4 - Number of children? 10 b) number reaching maturity? 9

Your maternal grandmother; home in city or country? --
1 - age when married?
2 - occupations?
3 - health? Good.
4 - age and cause of death? 92. "old age"

Your husband: nationality, if American, of what descent? German descent
1 - date of birth? 1859
2 - early life in city or country? City.
3 - height? Five feet, five in.
4 - weight? 135 lbs.
5 - muscular or weak? Muscular.
6 - Where educated? degrees if any? Butler, & Ind State U. - M.A. Ph. D. etc
7 - if a college man, has he been athletic? slightly
8 - complexion? Neither dark nor fair.
9 - temperament? Nervous
10 - does he use tobacco? No
11 - occupations? Teaching & work of Naturalist
12 - health? Good.
13 diseases in his family: Nervous Disorders? Rheumatism?
Consumption? Dyspepsia? Varicose veins? Heart Disease?
Hernia? Habitual Constipation? Catarrh?

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