243
Robert Carungis
28
Father alive. 50.
Engineer. Mother dead. Died of spinal disease at 20.
Age. Occupation.
Family History
Have you Ever Suffered from Rheumatic Fever? Never
Have you ever had spitting of blood? Never
Have you Ever Suffered from fits of any kind? Never
Have you ever suffered from Piles? No
Are you ruptured? No
Have you ever Suffered from Malaria? No
Have you Ever Suffered from Indigestion? Yes
Have you Ever suffered from Sore Eyes? Yes
Where was your last illness & the nature of it? 1877. Congestion of lungs.
I hereby certify that to the best of my knowledge the answers to the above questions are correct.
Signed Robert Carungis
July 11th 1884