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Blank No. 34 34 Series II. Form B. 1.

Date Dec. 30, 1897

Your Father: 1 - Nationality, if American, of what descent? American - English
What child this parent 1st, 2d or 3d Etc.? First

2 - Home in city or country before marriage? Country

3 - Home in city or country after marriage? Country

4 - Age when married? 24

5 - Occupations before your birth? Agriculture.
b) after your birth? Surgeon.

6 - Health previous to your birth? Good
b) - after your birth? Good.

7 - Number of children living, a) boys? 1 b) girls 3

8 - Number of children dead; give age at time of death and cause.
a) boys. b) girls.
Boy of 6, brain fever. Boy 30 typhoid fever, immediately heart
failure. Girl - infant. Girl 19[?] "Quick" Consumption.

9 - If your father is living, give his age and present health,
if dead, age at death and cause?
Died at 66 with typhoid fever, and heart failure.

10 - Name any diseases in his family.
Are none. All healthy.

Your paternal Grandfather: home in city or country? Country.

1 - Age when married?

2 - Occupations? Blacksmith.

3 - Health? Don't know.

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