The following questionaire is an electronic version of the printed one and is exactly the same except where an electronic submission makes certain data irrelevant. The following questionaire is for family history archives. It has been made as general as possible to handle all conditions; no questions are intended to imply anything about the person filling out the questionaire, either good or bad. If you find any question offensive, please feel free to ignore it. To provide for your security, no information provided will be given to anyone unless you specify that the information is public. Each section of the questionaire has a place for such a declaration. Information will be made available upon request for members of the family, and all information will become "public" one year following the death of the person filling out the questionaire. Please leave all unapplicable questions blank. If there is some piece of data you wish to have included in the archives but is not on the questionaire, please feel free to include it in the NOTES section. Thank you for taking the time to fill out this questionaire. The archives are kept in Burien, WA. Backup archives are kept in Seattle, WA. If you do not have the answers to a question in your mind, do not bother doing any research unless you would like to. Thank you for this biographical information. Would you kindly include a picture of yourself in your reply? A current picture (formal is best) is preferred, but baby pictures are a nice addition. =============================================================================== SECTION 1 All information in this section is PUBLIC. Name: ______________________ ____________ _____________ _______________________ First Middle 1 Middle 2 Last Title(s): __________________ Social Security Number: ___________________ Maiden Name: __________________________________________ Sex: _________________ Date of Birth: _________________________ Date of Death: ______________________ Place of Birth: ___________________ ___________________ _______________________ City County State/Provine ___________________ Country Place of Death: ___________________ ___________________ ________________________ City County State/Province ___________________ Country Cause of Death: ________________________ Age at Death: _______________________ =============================================================================== SECTION 2 Marriage Information Is this section PUBLIC? YES [] NO [] Full Maiden Name Date Married Date Divorced Place Married First Spouse _______________ _______________ _________________ ________________ Second Spouse _______________ _______________ _________________ ________________ Third Spouse _______________ _______________ _________________ ________________ Fourth Spouse _______________ _______________ _________________ ________________ =============================================================================== SECTION 3 Offspring Information Is this section PUBLIC? YES [] NO [] From oldest to youngest: Child # Name Date Born Date Died Place Born 1 ___________________ ___________________ _________________ ______________ 2 ___________________ ___________________ _________________ ______________ 3 ___________________ ___________________ _________________ ______________ 4 ___________________ ___________________ _________________ ______________ 5 ___________________ ___________________ _________________ ______________ 6 ___________________ ___________________ _________________ ______________ 7 ___________________ ___________________ _________________ ______________ 8 ___________________ ___________________ _________________ ______________ 9 ___________________ ___________________ _________________ ______________ 10 ___________________ ___________________ _________________ ______________ 11 ___________________ ___________________ _________________ ______________ 12 ___________________ ___________________ _________________ ______________ 13 ___________________ ___________________ _________________ ______________ 14 ___________________ ___________________ _________________ ______________ 15 ___________________ ___________________ _________________ ______________ =============================================================================== SECTION 4 Health Information Is this section PUBLIC? YES [] NO [] Current Age __________ Current Weight ___________ Current Height ____________ Eye Color ____________ Hair color _______________ Circle the appropriate response: Left-handed Right-handed Ambidextrous List operations from first to most recent: # Type of Operation Date Place Comments 1 ____________________________ ______________ ____________ ___________________ 2 ____________________________ ______________ ____________ ___________________ 3 ____________________________ ______________ ____________ ___________________ 4 ____________________________ ______________ ____________ ___________________ 5 ____________________________ ______________ ____________ ___________________ 6 ____________________________ ______________ ____________ ___________________ 7 ____________________________ ______________ ____________ ___________________ 8 ____________________________ ______________ ____________ ___________________ 9 ____________________________ ______________ ____________ ___________________ 10 ___________________________ ______________ ____________ ___________________ List diseases or medical conditions other than colds and flu: =============================================================================== SECTION 5 Schooling information Is this section PUBLIC? YES [] NO [] List all schools attended including K through 12, vocational, college, and all degrees. ---- dates ---- School Name School Location From To Major/Minor Degree _____________ __________________ _________ ________ _____________ ______________ _____________ __________________ _________ ________ _____________ ______________ _____________ __________________ _________ ________ _____________ ______________ _____________ __________________ _________ ________ _____________ ______________ _____________ __________________ _________ ________ _____________ ______________ _____________ __________________ _________ ________ _____________ ______________ _____________ __________________ _________ ________ _____________ ______________ _____________ __________________ _________ ________ _____________ ______________ =============================================================================== SECTION 6 Military Service Data Is this section PUBLIC? YES [] NO [] Branch of Service: ____________________ Drafted? YES [] NO [] Date Service Entered: ___________________ Date Service Left: _________________ Condition of Service Termination: _____________________________________________ Rank Acheived: _________________________ War(s) Served In: __________________ Commendations: _______________________________________________________________ Division/Ship/Battalion: _____________________________________________________ =============================================================================== SECTION 7 Vocational Information Is this section PUBLIC? YES [] NO [] Date Retired: ____________________ List jobs held from first to most recent: Company Name Position Date Hired Date Terminated Reason Salary _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ _____________ _____________ _____________ _________________ ________ __________ =============================================================================== SECTION 8 Geographical Profile Is this section PUBLIC? YES [] NO [] List locations lived in from first to most recent: ---- date ---- Street Address Apt # City County State Country From To ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ ________________ _________ _________ ________ ________ _________ _______ ______ =============================================================================== SECTION 9 Lineage Information Is this section PUBLIC? YES [] NO [] Ethnic Background (example: 25% german, 25% irish, 25% dutch, 25% unknown): Family Information: Who Name Date Born Date Died Place Born Place Died FATHER __________________ _____________ _____________ _____________ ____________ MOTHER __________________ _____________ _____________ _____________ ____________ Siblings (oldest to youngest): __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ __________________ _____________ _____________ _____________ ____________ ================================================================================ SECTION 10 Private This section is NOT PUBLIC Your Social Security Number/Immigration ID: =============================================================================== SECTION 11 Misc Is this section PUBLIC? YES [] NO [] Religion: ___________________________ Denomination/Sect: ____________________ Baptism date: _______________________ Baptism Place: ________________________ Dedication date: ____________________ Dedication Place: _____________________ Prison sentances served: ----- Date ----- Sentance Served At From To __________________________ ______________ ___________ ____________ __________________________ ______________ ___________ ____________ __________________________ ______________ ___________ ____________ __________________________ ______________ ___________ ____________ Any history of alcoholism? [] YES [] NO Any history of smoking? [] YES [] NO Any history of narcotics? [] YES [] NO Any history of chewing tabbaco? [] YES [] NO What are your interests, hobbies, talents, achievements, etc? Any comments you would like to make for the record (NOTES)?