229
Ravie.
age Occupation
Family History
Peebles.
Fathers
42 years
Surveyor in the Board of Trade
56 drowned at Sea
age mothers age 70 living
Hand Joins Ever had Rheumatic Fever
No
No
Have you Ever had pulling of blood?
No
Have you Ever had Small pox?
No
Have you Ever been ruptured?
No
Have you Ever suffered from fits of any kind
Ever had Hydrocele.
Ever served abroad?
Ever suffered from Headache: Rheumatism
Have you Ever Suffered from the Eyes. Ophthalmia
Ever had fever ague.
No
I hereby certify to the best of my knowledge &
belief the answers to the above questions are
Correct:
Signed-
Examined by Peebles
No:
No:
No:
Yes
Never Severely
No:
17.6.90
for Certificate
See 4th page hereof