Naturalized? (yes or no) Number of children living and their ages? Former occupation? At what age was earning power impaired? Amount of income derived from property holdings, savings, pensions, insurance, 29. Property above debts at any time? 31. Length of time and what members of family were sick during past year? 7. Conjugal condition? 9. If not, with whom or where? Loss of earning power due to what? If widow, occupation and wages of husband? Property above debts at any time? What is loss due to? Number of children living and their ages? Extent of their ability to help support? support? 17. Any other near relatives able or willing to help? 18. Present sources of income? 19. Amount of such per week? 21. Weekly wages then earned? 23. If widow, occupation and wages of husband? Property above debts at any time? 24. 26. Amount of property when admitted? Investigator, Date, (Reverse side may be used for additional remarks.) |