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Blank No. 22 22 Series II. Form B. 1.

Date Sept. 1897.

I - Your Father: 1 - Nationality, if American of what descent? American, English
2 - Home in city or country before marriage? City
3 - Home in city or country after marriage? City
4 - Age when married? Twenty-five (?)
5 - Occupations before your birth? Physician
b) after your birth? Physician
6 - Health previous to your birth? Excellent
b) - after your birth? Excellent
7 - Number of children living; a) boys? Two b) girls Four
8 - Number of children dead; give age at time of death and cause.
a) boys. b) girls.
One boy: dead from fever caused by accidental
blow upon the head at six (?) mos.
9 - If your father is living, give his age and present health,
if dead, age at death and cause?
Sixty. Excellent.
10 - Name any diseases in his famly. Catarrh
Piles

II - Your Paternal Grandfather: home in city or country? Growing country
town.
1 - Age when married? -----?
2 - Occupations? Farmer & lawyer.
3 - Health? Excellent.

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