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Blank No. 6 Series II. Form B. 2.

I (continued) 4 - Number of children? Three. Number reaching maturity? all

I Your Paternal Grandmother: home in city or country? village.

1 - age when married? ---

2 - occupations? ---

3 - health? She was an invalid for many years.

4 - age and cause of death? ---

2 - Your Mother: 1 - Nationality, if American of what descent? German.

2 - home in city or country before marriage? Village.

b) home in city or country after marriage? City.

3 - Occupations before her marriage? Student.

b) after her marriage? Teacher and student.

4 - Note any prenatal influences before your birth. ---

5 - Her health previous to your birth? Good.

b - after your birth? Later in life heart disease developed and
she was not very strong

6 - Number of miscarriages? ---

7 - Her age if living and present health? 75 if not, age at time
of death and cause? Health good.

8 - How was your mother's health affected by the climacteric
(change of life). not at all, as far as I know.

9 - name any diseases in her family. Her mother had chronic headache.

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