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294

Life and Letters of Francis Galton

For Private Information only.
QUESTIONS A, CONCERNING THE KINDRED OF THE APPLICANT.

On the Fraternity consisting of the Applicant and of his whole Brothers and Sisters. Write A by the side of the figure in the first column that refers to the Apirlicant.

 

Register

Names or Initials

in order of Birth

Sex

M. or F.

If deceased

Age at Death

Cause of Death

1

2

       

Register

Initials

Notable achievements of any brother or sister of the Applicant that fall

within the purview of this Certificate

     

We certify that to the best of our knowledge the above account is correct, also that with the exceptions mentioned below, no member of this Fraternity has ever suffered from Insanity, Epilepsy or other severe form of nervous disease.

Exceptions giving full particulars. If no
exceptions write the word "None "

Signatures of Writer of the above notice. The Applicant.

The last paragraph and the corresponding paragraphs of Questions B and C must be on a separate sheet marked "confidential." F. G.


QUESTIONS B, CONCERNING THE KINDRED OF THE APPLICANT.

On the Fraternity consisting of the Father of the Applicant and of the Father's whole brothers and sisters. Write F by the side of the figure in the first column that refers to the Father, and describe his achievements more fully than those of his brothers.

 
     

If deceased

Register

Regi

Names or Initials

in order of Birth

Sex

M. or F.

   

Age at Death

Cause of Death

1

       

2

       

3

       

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