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No. 9 Series II. Form B. 4

II. Yourself: 1. date of birth? 15 Aug 1834
2 - Early life in city or country? [checkmark on country]
3 - height? 5 ft. 7 in
4 - weight? 150
5 complexion? florid when young
6 temperament?
7 - where educated, give degree if any? Burr & Burton [L?]
8 - Occupations before marriage? a) in city or country? [checkmark above country] b) time spent in each? In school from 6 to 20 yrs. taught in
country school 2 yrs
9 - diseases in your family? from father or mother's side?
Nervous disorders? Rheumatism? [checkmark above and M] Consumption? [F above] Dyspepsia? [F above]
Varicose veins? Heart Disease? [M above] Hernia? Habitual Constipation?
Catarrh
10 - General Health before marriage? [good written above] b) since marriage? [good written above]
Paralysis? Brain Fever? Chronic Headache? [sick written above] Nervous Prostation?
Catarrh? [checkmark above and Slight written beside] Hernia? Dispepsia? Habitual Constipation? [checkmark and tendency written above] Inflammation
of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting
Blood? Consumption? Laryngitis? Tonsilitis? Insomnia
? Rheumatism? Pneumonia? Jaundice? Varicose Veins?
Any other diseases? Gout in toe

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No. 9 Series II. Form B. 4

II. Yourself: 1. date of birth? 15 Aug 1834
2 - Early life in city or country? [checkmark on country]
3 - height? 5 ft. 7 in
4 - weight? 150
5 complexion? florid when young
6 temperament?
7 - where educated, give degree if any? Burr & Burton [L?]
8 - Occupations before marriage? a) in city or country? [checkmark above country] b) time spent in each? In school from 6 to 20 yrs. [l? c?] school 2 yrs
9 - diseases in your family? from father or mother's side?
Nervous disorders? Rheumatism? [checkmark above and M] Consumption? [F above] Dyspepsia? [F above]
Varicose veins? Heart Disease? [M above] Hernia? Habitual Constipation? Catarrh
10 - General Health before marriage? [good written above] b) since marriage? [good written above] Paralysis? Brain Fever? Chronic Headache? [sick written above] Nervous Prostation?
Catarrh? [checkmark above and Slight written beside] Hernia? Dispepsia? Habitual Constipation? [checkmark and tendency written above] Inflammation of Bowels? Pleurisy? Bronchitis? Shortness of Breath? Spitting Blood? Consumption? Laryngitis? Tonsilitis? Insomnia? Rheumatism? Pneumonia? Jaundice? Varicose Veins?
Any other diseases? Gout in toe

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