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Blank no. 4 4 Form A.
1. Name in full. arried? Twenty-nine a) before marriage fair b)after marriage fair
2. Address.
3. Date of birth. October 13 - 1857
4.Place of birth. Windham, Connecticut Temperment.
5.Where educated; give degrees if any. Occupation before marriage. Give length of time spent in each. In public & private schools of Conn. Typewriting - one year - Accountant in St. R.R. office about one year. (Baltimore)
6. Nationality of mother. American ([deleted] Dutch [deleted] - English)
7. Nationality of father. American (Dutch - Irish - English)
8.Age of [deleted]father[deleted] [inserted]mother[inserted] when married? Twenty-three
9 Age of [deleted]mother[deleted] [inserted]father[inserted] when married? Twenty-two
10 general health of parents? Fair
11.Nationality of husband. American (New England)
12. Date of birth of husband. Jan 26 - 1859
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Blank no. 4 Form B.
Date. May 12, 1892.
1.Age when you married? Twenty-nine
2. General health a) before marriage fair b) after marriage fair
[deleted]3.[deleted]
3.What knowledge of sexual physiology had you before marriage? Not any.
4. Number of times married? If more than once additional blanks will be furn ished you to answer the following question separately in regard to each mar riage.
5.number of years married? Six.
6.Do you habitually sleep with your husband? Yes.
Number of conceptions?
8.number of children? State in connection with each, Date of birth, sex,, whether healthy or not; Note any characteristic and the cause if you can give it.
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Blank no. 4 2
9.Did conception occur by choice or accident?
10. Habit of intercourse? average number of times per week? per month? per year? Possibly 6 or 8
11.Was intercourse held during pregnancy? If so, how often? b)did you desire it during this period?
12.At other times have you any desire for intercourse? Yes. a)How often? b)At what time in relation to your menses? The menses do not seem to make much difference
13.Is intercourse agreeable to you or not? Sometmes agreeble but often disagreeable Do you always have a venereal orgasm? No.
1) when you do, a) effect immediately afterward Usually beneficial b) effect next day? Sometimes increased vitality not always
2)When you do not,a) effect immediately after? Nervousness. b) effect next day? Sometimes exhaustion - not always.
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Blank No. 4 3.
14. What do you believe to be the purpose of intercourse? a) Necessity To the man? Think it depends upon previous training in self control. Do not think it is an absolute necessity. To the woman?
b) Pleasure? The pleasure is the smallest part.
c) Reproduction? I believe that to be the main purpose.
15. Have you ever used any means to prevent conception? If so a) What? b) What was the effect on your health? Yes - A cover for the male organ - Not injurious to my health.
18.What to you would be an ideal habit? One governed by self control & the desire for offspring.
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Blank No. 5 Form A.
1. Name in full.
2. Address.
3. Date of birth. Aug. 10, 1864.
4. Place of birth. Phoenix N.Y. Temperment.
5. Where educated 2 Give degrees if any. 3 Occupations before marriage. 4 length of time spent in each. Phoenix Acad. Cornell Univ. - 2 B.S. 3 - School teaching 4- Four years.
8.Nationality of mother. American (from N.Y. dutch)
7. Nationality of father. " (" Eng.)
8.Age when father was married. Thirty one
9. Age of mother when married. Twenty five
10.General health of parents.... good.
11.Nationality of husband. American (Dutch)
12. Date of birth of husband. Oct 26, 1855
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