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Blank No.36 Series II Form B.
Date: June 21, 1895
I. Your Father: 1- Nationality, if American, of what descent? German
2- Home in city or country before marriage? [Country?]
3- Home in city or country after marriage? [City?]
4- Age when married? 25
5- Occupations before your birth? Tanner.
(b)After your birth? Wholesale leather dealer
6- Health previous to your birth? Excellent. Suffered from youth from hemorrhoids a result of disease.
(b)After your birth? Excellent with occassional [touches?] of constipation.
7- Number of children living, (a)boys?1 (b)girls?1
8- Number of children dead; give age at time of death and cause.
(a)boys.1. (b)girls.0. waked from a sound sleep. vaccinated in the fashion of 25 years ago. Ate a heavy supper waked up in night ill, [and?] two days after died in convulsions. Had aways been perfectly healthy.
9-If your father is living, give his age and present health, if dead, age at death and cause? 59. Health very good.
10- Name any diseases in his family. Catarrh. One of sisters = enlarged gland in neck.

II. Your Paternal Grandfather: home in city or country? [Country?]
1- Age when married?
2- Occupations? Farmer
3- Health? Very good