77

No. 9 Series II. Form B. 3.

- Your Maternal Grandfather: home in city or country? [checkmark above country]
1 - Age when married? 17
2 - occupations? farmer, ([perth?] in his [?] salary of $2000.
3 - health? good
4 - number of children? 5 b) number reaching maturity? All

- Your maternal grandmother: home in city or country? [checkmark above country]
1 - Age when married? 16
2 - Occupations? housework
3 - health? good until change of life rheumations & heart disease
helpless for 20 years.
4 - age and cause of death? about 70, opium eater in old age

I - Your husband: nationality, if American, of what descent? Am.(French? - English
1 - date of birth? Feb.21.1829
2 - early life in city or country? [checkmark above country]
3 - height? 6ft - or 6ft 1in
4 - weight? when married 140 lbs. about 140 or 150
5 - muscular or weak? [checkmark above weak] Poultney Vt. New Brunswick N.S. Prep School.
Albany Med. Col. M.D.
6 - Where educated? degrees if any? [arrow pointing to above answer]
7 - if a college man, has he been athletic? NO
8 - complexion? fair with dark hair & eyes
9 - temperament? nervous
10 - does he use tobacco? as a young man smoked incessantly
until 40 yr. stopped [?]
11 - Occupations? Teacher and Physician
12 - health? Very delicate always. dyspeptic &
as threatened with consumption as a young man but overcame
tendency. Insane from use of morphine at 39 or 40 for 2 yrs
. 6.m after birth of child
[In margin] Took morphine from 1861 to 1870. Relapsed into habit once about 7 or 8 yrs later but overcame it without going to an Asylum?
13 - diseases in his family: nervous disorders ? Rheumatism?
Consumption? [check mark above and written B + M's. F] Dyspepsia? [checkmark above] Varicose veins? Heart Disease?
Hernia? [checkmark above] Habitual Constipation? [checkmark above] Catarrh? Consumption of bowels

-135 -

[written in red] Copy of Note on inside edge of this sheet -
"Took morphine from 1861 to 1870. Relapsed into habit once about 7 or 8 yrs later but overcame it without going to asylum"