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Show 15. Are responsibilities calmly and cheerfully borne? or do they produce disquietude, anxiety, sleepless nights, and care? 6\yy* , %4* , 16. State, as far as you know, what was the age at death, cause of death, and duration of final illness of each of the following persons, if deceased. What is the age and present state of health of each of them, if now living ? If you do not know, please inquire and report. Please be as explicit as possible. Father Brothers y>\ *x •?jk. Father's Father Father's Mother Mother's Father Mother's Mother; Age, if living. en 3 z se X7 XH IX-State of Health. w >=«-^» x<L=KyX yct+*~*yy*. T" HbtM-y*™*XA>j jyyty*yL Az<y-<yZy r\AyX^-yc . y\uytCy ri&^y*y*<>-***%yy± (UuMi Age at death. nr e% JTO 13 Go Cause of Death. kst£& JU^yy^ l^yyUytyxyC^ x) AX* fU^.yf.yy^, . fy\y<y y^lC i<^ ^/- c^yAVA^yy y.4yyyC*y€-y*y+A3 i C t ^ y^yXyty^i leXyay^yyi-y^ » * a > ^ *' i ytyo^^-xyyy (5 S^c-XyACi "• H^jfrj*- o c <^yCy£yO [Remember especially to make reference to Consumption, Scrofula, Insanity, Deafness, Epilepsy, or Heart-diseases, from which near relatives may have suffered^] 17. Is there anything, or has there been anything, in your physical condition, family or personal history or habits, tending to shorten your life or to impair your usefulness, which is not distinctly set forth above? y\yy<y~\y \\yy"ly>tyyCyyi 1 f N.B.- Please state date of birth. JJ JZy*£y-iy*ytyAyyy z, i *T / $~ f X S.yy>.<*^ Dated at .k..j^y^.c^a^ %M....r.3y^xxxy^j H r9o % When filled, to be forwarded to * Signature of Applicant. SECRETARIES OF A. B. C. F. M., Congregational House, BOSTON, MASS. |