13

Blank Form A.

1. Name in full.

2. Address.

3. Date of birth. February 8th 1867

4. Place of birth. New Gloucester Maine.
Temperment.

5. Where educated : give degress if any. Occupations before marriage giving length
of time spent in each.
Pa. State College. Taught music more or less for five years. During
that time taught two terms of country school. Practiced piano a great
deal over two or three years during [?] [?] and four years.

6. Nationality of mother. American.

7. Nationality of father. American.

8. Age of mother when married. About twenty-five.

9. [deleted] 10. [deleted] Age of father when married. About twenty-seven.

10. General health of parents. Well & robust.

11. Nationality of husband. American.

12. [deleted] Age of [deleted] [inserted] Date of Birth of [inserted] husband. [deleted]at present time.[deleted] 1869

Notes: Perfectly well baby until a mo. old. [?] sudden change of food
impaired digestion, [?] trouble, sleeplessness, nervousness.