Life of Francis Galton by Karl Pearson Vol 3a : image 0347

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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.
Register Regi	Names or Initials in order of Birth	Sex M. or F.	Age at Death	Cause of Death
1
2
3

OCR Rendition - approximate