| Name | Residence when at home. City or town or township? | Is he (or she) self supportng or partly so (see note B) | Age at which deafness occurred. | Supposed cause of deafness, if acquired | Is this person semi-mute? | Is this person semi-deaf? | Has this person ever been an inmate of an institution for deaf-mute? If yes, give the name of institution. | What has been the total length of time spent in institution? | Date of this person's discharge. (Give year only) | Is this person also insane? | Is this person also idiotic? | Is this person also blind? |
