YELLOW instructions for all charts YELLOW

+-----------------------------------------------------------------------+
| GENERAL: Use the following chart colors:                              |
|                                                                       |
| > PINK: Relatives on your mother\'s side                              |
| >                                                                     |
| > BLUE: Relatives on your father\'s side                              |
| >                                                                     |
| > WHITE: Your sisters and brothers and nieces and nephews             |
| >                                                                     |
| > GREEN: Your children                                                |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| We suggest that you complete the information for each relative on the |
| chart before you complete the charts for the children of those        |
| relatives.                                                            |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+
| Complete a separate children\'s chart for any children by a previous  |
| marriage.                                                             |
|                                                                       |
| Example: If Alice M. Doe (current spouse of John Doe) had children by |
| a previous spouse, complete a separate chart for those children. List |
| Alice M. Doe and her previous husband, Kenneth J. Wood, as the        |
| parents, in the space for parent\'s names at the top of the           |
| children\'s chart.                                                    |
+-----------------------------------------------------------------------+

+-----------------------------------------------------------------------+
| ![](media/image1.wmf){width="1.4569444444444444in"                    |
| height="1.1611111111111112in"}                                        |
|                                                                       |
| > ![](media/image2.png){width="9.590972222222222in"                   |
| > height="3.520138888888889in"}                                       |
+-----------------------------------------------------------------------+

BE SURE TO FOLLOW ANY INSTRUCTIONS AT THE BOTTOM OF THE CHART.

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | **BL |         |     |
| whose |              | AUNTS'   |        |   | UE** |         |     |
| chi   |              | AND      |        |   |      |         |     |
| ldren |              | UNCLES'  |        |   |      |         |     |
| does  |              | CHART\   |        |   |      |         |     |
| this  |              | (Your    |        |   |      |         |     |
| chart |              | F        |        |   |      |         |     |
| ref   |              | ather\'s |        |   |      |         |     |
| er?** |              | Sisters  |        |   |      |         |     |
|       |              | and      |        |   |      |         |     |
| **    |              | Bro      |        |   |      |         |     |
|  / ** |              | thers)** |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Fathe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Fathe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Fathe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Fathe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Fathe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Fathe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Fathe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Fathe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Fathe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Fathe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Fathe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Fathe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED SPACE FOR MORE AUNTS AND UNCLES (YOUR FATHER\'S SISTERS
AND BROTHERS), FILL OUT THE BACK SIDE OF THIS CHART OR START A NEW
[BLUE]{.underline} AUNTS AND UNCLES CHART. IF YOU HAVE COMPLETED
INFORMATION ON ALL OF YOUR FATHER\'S SISTERS AND BROTHERS AND THEIR
CHILDREN, GO BACK TO PAGE 12 OF THE QUESTIONNAIRE.**

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | **BL |         |     |
| whose |              | AUNTS'   |        |   | UE** |         |     |
| chi   |              | AND      |        |   |      |         |     |
| ldren |              | UNCLES'  |        |   |      |         |     |
| does  |              | CHART\   |        |   |      |         |     |
| this  |              | (Your    |        |   |      |         |     |
| chart |              | F        |        |   |      |         |     |
| ref   |              | ather\'s |        |   |      |         |     |
| er?** |              | Sisters  |        |   |      |         |     |
|       |              | and      |        |   |      |         |     |
| **    |              | Bro      |        |   |      |         |     |
|  / ** |              | thers)** |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Fathe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Fathe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Fathe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Fathe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Fathe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Fathe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Fathe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Fathe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Fathe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Fathe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Fathe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Fathe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED SPACE FOR MORE AUNTS AND UNCLES (YOUR FATHER\'S SISTERS
AND BROTHERS), FILL OUT THE BACK SIDE OF THIS CHART OR START A NEW
[BLUE]{.underline} AUNTS AND UNCLES CHART. IF YOU HAVE COMPLETED
INFORMATION ON ALL OF YOUR FATHER\'S SISTERS AND BROTHERS AND THEIR
CHILDREN, GO BACK TO PAGE 12 OF THE QUESTIONNAIRE.**

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | **PI |         |     |
| whose |              | AUNTS'   |        |   | NK** |         |     |
| chi   |              | AND      |        |   |      |         |     |
| ldren |              | UNCLES'  |        |   |      |         |     |
| does  |              | CHART\   |        |   |      |         |     |
| this  |              | (Your    |        |   |      |         |     |
| chart |              | M        |        |   |      |         |     |
| ref   |              | other\'s |        |   |      |         |     |
| er?** |              | Sisters  |        |   |      |         |     |
|       |              | and      |        |   |      |         |     |
| **    |              | Bro      |        |   |      |         |     |
|  / ** |              | thers)** |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Mothe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Mothe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Mothe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Mothe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Mothe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Mothe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Mothe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Mothe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Mothe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Mothe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Mothe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Mothe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED SPACE FOR MORE AUNTS AND UNCLES (YOUR MOTHER\'S SISTERS
AND BROTHERS), FILL OUT THE BACK SIDE OF THIS CHART OR START A NEW
[PINK]{.underline} AUNTS AND UNCLES CHART. IF YOU HAVE COMPLETED
INFORMATION ON ALL OF YOUR MOTHER\'S SISTERS AND BROTHERS, GO BACK TO
THE GRANDPARENTS CHART IN THE QUESTIONNAIRE AND SEE OF YOU NEED TO FILL
OUT A CHART FOR YOUR MOTHER\'S SISTERS AND BROTHERS.**

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | **PI |         |     |
| whose |              | AUNTS'   |        |   | NK** |         |     |
| chi   |              | AND      |        |   |      |         |     |
| ldren |              | UNCLES'  |        |   |      |         |     |
| does  |              | CHART\   |        |   |      |         |     |
| this  |              | (Your    |        |   |      |         |     |
| chart |              | M        |        |   |      |         |     |
| ref   |              | other\'s |        |   |      |         |     |
| er?** |              | Sisters  |        |   |      |         |     |
|       |              | and      |        |   |      |         |     |
| **    |              | Bro      |        |   |      |         |     |
|  / ** |              | thers)** |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Mothe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Mothe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Mothe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Mothe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Mothe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Mothe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Mothe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Mothe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Mothe | [(           |          | Yes No | \ |      | Name of | \   |
| r\'s\ |              |          | DK     | | |      | H       | _\_ |
| s     |          ) ] |          |        | \ |      | ospital | \_\ |
| ister | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
| Mothe | Last First   |          | site   | _ |      |         | _\_ |
| r\'s\ | Middle       |          | Year   | \ |      | County  |     |
| br    | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| Mothe | Address      |          | where  | \ |      | ysician | *   |
| r\'s\ |              |          | dia    | _ |      | (if     | *GO |
| h     | City State   |          | gnosed | \ |      | known)  | B   |
| alf-s | Zip          |          |        | | |      |         | ACK |
| ister |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
| Mothe | [            |          |        | \ |      |         | STI |
| r\'s\ |  (           |          |        | _ |      |         | ONN |
| ha    |          ) ] |          |        | \ |      |         | AIR |
| lf-br | {.underline} |          |        | _ |      |         | E** |
| other |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED SPACE FOR MORE AUNTS AND UNCLES (YOUR MOTHER\'S SISTERS
AND BROTHERS), FILL OUT THE BACK SIDE OF THIS CHART OR START A NEW
[PINK]{.underline} AUNTS AND UNCLES CHART. IF YOU HAVE COMPLETED
INFORMATION ON ALL OF YOUR MOTHER\'S SISTERS AND BROTHERS, GO BACK TO
THE GRANDPARENTS CHART IN THE QUESTIONNAIRE AND SEE OF YOU NEED TO FILL
OUT A CHART FOR YOUR MOTHER\'S SISTERS AND BROTHERS.**

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | *    |         |     |
| whose |              | \        |        |   | *GRE |         |     |
| chi   |              | CH       |        |   | EN** |         |     |
| ldren |              | ILDREN'S |        |   |      |         |     |
| does  |              | CHART**  |        |   |      |         |     |
| this  |              |          |        |   |      |         |     |
| chart |              |          |        |   |      |         |     |
| ref   |              |          |        |   |      |         |     |
| er?** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **    |              |          |        |   |      |         |     |
|  / ** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| dau   | [(           |          | Yes No | \ |      | Name of | \   |
| ghter |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| son   | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician |     |
|       |              |          | dia    | _ |      | (if     |     |
|       | City State   |          | gnosed | \ |      | known)  |     |
|       | Zip          |          |        | | |      |         |     |
|       |              |          | City   | \ |      |         |     |
|       | Phone:       |          | State  | _ |      |         |     |
|       | [            |          |        | \ |      |         |     |
|       |  (           |          |        | _ |      |         |     |
|       |          ) ] |          |        | \ |      |         |     |
|       | {.underline} |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| dau   | [(           |          | Yes No | \ |      | Name of | \   |
| ghter |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| son   | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician |     |
|       |              |          | dia    | _ |      | (if     |     |
|       | City State   |          | gnosed | \ |      | known)  |     |
|       | Zip          |          |        | | |      |         |     |
|       |              |          | City   | \ |      |         |     |
|       | Phone:       |          | State  | _ |      |         |     |
|       | [            |          |        | \ |      |         |     |
|       |  (           |          |        | _ |      |         |     |
|       |          ) ] |          |        | \ |      |         |     |
|       | {.underline} |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| dau   | [(           |          | Yes No | \ |      | Name of | \   |
| ghter |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| son   | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician |     |
|       |              |          | dia    | _ |      | (if     |     |
|       | City State   |          | gnosed | \ |      | known)  |     |
|       | Zip          |          |        | | |      |         |     |
|       |              |          | City   | \ |      |         |     |
|       | Phone:       |          | State  | _ |      |         |     |
|       | [            |          |        | \ |      |         |     |
|       |  (           |          |        | _ |      |         |     |
|       |          ) ] |          |        | \ |      |         |     |
|       | {.underline} |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED SPACE FOR MORE CHILDREN, USE THE OTHER SIDE OF THIS CHART
OR START A NEW [GREEN]{.underline} CHART FOR YOUR CHILDREN. IF YOU HAVE
COMPLETED INFORMATION ON ALL OF YOUR CHILDREN WITH ALL OF YOUR SPOUSES,
GO BACK TO THE QUESTIONNAIRE AND COMPLETE THE PARENTS' CHART. IF YOU
HAVE ANY GRANDCHILDREN WHO HAVE HAD CANCER, FILL OUT INFORMATION ON
THESE GRANDCHILDREN ON THE ADDITIONAL RELATIVES CHART AT THE BACK OF THE
QUESTIONNAIRE.**

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | *    |         |     |
| whose |              | \        |        |   | *GRE |         |     |
| chi   |              | CH       |        |   | EN** |         |     |
| ldren |              | ILDREN'S |        |   |      |         |     |
| does  |              | CHART**  |        |   |      |         |     |
| this  |              |          |        |   |      |         |     |
| chart |              |          |        |   |      |         |     |
| ref   |              |          |        |   |      |         |     |
| er?** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **    |              |          |        |   |      |         |     |
|  / ** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| dau   | [(           |          | Yes No | \ |      | Name of | \   |
| ghter |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| son   | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician |     |
|       |              |          | dia    | _ |      | (if     |     |
|       | City State   |          | gnosed | \ |      | known)  |     |
|       | Zip          |          |        | | |      |         |     |
|       |              |          | City   | \ |      |         |     |
|       | Phone:       |          | State  | _ |      |         |     |
|       | [            |          |        | \ |      |         |     |
|       |  (           |          |        | _ |      |         |     |
|       |          ) ] |          |        | \ |      |         |     |
|       | {.underline} |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| dau   | [(           |          | Yes No | \ |      | Name of | \   |
| ghter |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| son   | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician |     |
|       |              |          | dia    | _ |      | (if     |     |
|       | City State   |          | gnosed | \ |      | known)  |     |
|       | Zip          |          |        | | |      |         |     |
|       |              |          | City   | \ |      |         |     |
|       | Phone:       |          | State  | _ |      |         |     |
|       | [            |          |        | \ |      |         |     |
|       |  (           |          |        | _ |      |         |     |
|       |          ) ] |          |        | \ |      |         |     |
|       | {.underline} |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| dau   | [(           |          | Yes No | \ |      | Name of | \   |
| ghter |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| son   | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician |     |
|       |              |          | dia    | _ |      | (if     |     |
|       | City State   |          | gnosed | \ |      | known)  |     |
|       | Zip          |          |        | | |      |         |     |
|       |              |          | City   | \ |      |         |     |
|       | Phone:       |          | State  | _ |      |         |     |
|       | [            |          |        | \ |      |         |     |
|       |  (           |          |        | _ |      |         |     |
|       |          ) ] |          |        | \ |      |         |     |
|       | {.underline} |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED SPACE FOR MORE CHILDREN, USE THE OTHER SIDE OF THIS CHART
OR START A NEW [GREEN]{.underline} CHART FOR YOUR CHILDREN. IF YOU HAVE
COMPLETED INFORMATION ON ALL OF YOUR CHILDREN WITH ALL OF YOUR SPOUSES,
GO BACK TO THE QUESTIONNAIRE AND COMPLETE THE PARENTS' CHART. IF YOU
HAVE ANY GRANDCHILDREN WHO HAVE HAD CANCER, FILL OUT INFORMATION ON
THESE GRANDCHILDREN ON THE ADDITIONAL RELATIVES CHART AT THE BACK OF THE
QUESTIONNAIRE.**

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | *    |         |     |
| whose |              | \        |        |   | *WHI |         |     |
| chi   |              | SISTERS' |        |   | TE** |         |     |
| ldren |              | AND      |        |   |      |         |     |
| does  |              | B        |        |   |      |         |     |
| this  |              | ROTHERS' |        |   |      |         |     |
| chart |              | CHART**  |        |   |      |         |     |
| ref   |              |          |        |   |      |         |     |
| er?** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **    |              |          |        |   |      |         |     |
|  / ** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *Moth |              |          |        |   |      |         |     |
| er\'s |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fath  |              |          |        |   |      |         |     |
| er\'s |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| S     | [(           |          | Yes No | \ |      | Name of | \   |
| ister |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| Br    | {.underline} |          | Type   | _ |      |         | _\_ |
| other |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
| Ha    | Middle       |          | Year   | \ |      | County  |     |
| lf-Br | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| (same | Address      |          | where  | \ |      | ysician | F   |
| mo    |              |          | dia    | _ |      | (if     | ILL |
| ther) | City State   |          | gnosed | \ |      | known)  | O   |
|       | Zip          |          |        | | |      |         | UT\ |
| Ha    |              |          | City   | \ |      |         | A   |
| lf-Br | Phone:       |          | State  | _ |      |         | [   |
| other | [            |          |        | \ |      |         | WHI |
|       |  (           |          |        | _ |      |         | TE] |
| (same |          ) ] |          |        | \ |      |         | {.u |
| fa    | {.underline} |          |        | _ |      |         | nde |
| ther) |              |          |        | \ |      |         | rli |
|       | Area Code    |          |        | _ |      |         | ne} |
| H     | Number       |          |        | \ |      |         | CH  |
| alf-S |              |          |        | _ |      |         | ART |
| ister | Date of      |          |        | \ |      |         | FOR |
|       | Birth:       |          |        | | |      |         | NIE |
| (same | MO           |          |        | \ |      |         | CES |
| mo    | \_\_\_\_\_\_ |          |        | _ |      |         | AND |
| ther) | DAY          |          |        | \ |      |         | NE  |
|       | \_\_\_\_\_\_ |          |        | _ |      |         | PHE |
| H     | YR           |          |        | \ |      |         | WS. |
| alf-S | \_\_\_\_\_\_ |          |        | _ |      |         |     |
| ister |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
| (same |              |          |        | \ |      |         |     |
| fa    |              |          |        | _ |      |         |     |
| ther) |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| S     | [(           |          | Yes No | \ |      | Name of | \   |
| ister |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| Br    | {.underline} |          | Type   | _ |      |         | _\_ |
| other |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
| Ha    | Middle       |          | Year   | \ |      | County  |     |
| lf-Br | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| (same | Address      |          | where  | \ |      | ysician | F   |
| mo    |              |          | dia    | _ |      | (if     | ILL |
| ther) | City State   |          | gnosed | \ |      | known)  | O   |
|       | Zip          |          |        | | |      |         | UT\ |
| Ha    |              |          | City   | \ |      |         | A   |
| lf-Br | Phone:       |          | State  | _ |      |         | [   |
| other | [            |          |        | \ |      |         | WHI |
|       |  (           |          |        | _ |      |         | TE] |
| (same |          ) ] |          |        | \ |      |         | {.u |
| fa    | {.underline} |          |        | _ |      |         | nde |
| ther) |              |          |        | \ |      |         | rli |
|       | Area Code    |          |        | _ |      |         | ne} |
| H     | Number       |          |        | \ |      |         | CH  |
| alf-S |              |          |        | _ |      |         | ART |
| ister | Date of      |          |        | \ |      |         | FOR |
|       | Birth:       |          |        | | |      |         | NIE |
| (same | MO           |          |        | \ |      |         | CES |
| mo    | \_\_\_\_\_\_ |          |        | _ |      |         | AND |
| ther) | DAY          |          |        | \ |      |         | NE  |
|       | \_\_\_\_\_\_ |          |        | _ |      |         | PHE |
| H     | YR           |          |        | \ |      |         | WS. |
| alf-S | \_\_\_\_\_\_ |          |        | _ |      |         |     |
| ister |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
| (same |              |          |        | \ |      |         |     |
| fa    |              |          |        | _ |      |         |     |
| ther) |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| S     | [(           |          | Yes No | \ |      | Name of | \   |
| ister |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| Br    | {.underline} |          | Type   | _ |      |         | _\_ |
| other |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
| Ha    | Middle       |          | Year   | \ |      | County  |     |
| lf-Br | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| (same | Address      |          | where  | \ |      | ysician | F   |
| mo    |              |          | dia    | _ |      | (if     | ILL |
| ther) | City State   |          | gnosed | \ |      | known)  | O   |
|       | Zip          |          |        | | |      |         | UT\ |
| Ha    |              |          | City   | \ |      |         | A   |
| lf-Br | Phone:       |          | State  | _ |      |         | [   |
| other | [            |          |        | \ |      |         | WHI |
|       |  (           |          |        | _ |      |         | TE] |
| (same |          ) ] |          |        | \ |      |         | {.u |
| fa    | {.underline} |          |        | _ |      |         | nde |
| ther) |              |          |        | \ |      |         | rli |
|       | Area Code    |          |        | _ |      |         | ne} |
| H     | Number       |          |        | \ |      |         | CH  |
| alf-S |              |          |        | _ |      |         | ART |
| ister | Date of      |          |        | \ |      |         | FOR |
|       | Birth:       |          |        | | |      |         | NIE |
| (same | MO           |          |        | \ |      |         | CES |
| mo    | \_\_\_\_\_\_ |          |        | _ |      |         | AND |
| ther) | DAY          |          |        | \ |      |         | NE  |
|       | \_\_\_\_\_\_ |          |        | _ |      |         | PHE |
| H     | YR           |          |        | \ |      |         | WS. |
| alf-S | \_\_\_\_\_\_ |          |        | _ |      |         |     |
| ister |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
| (same |              |          |        | \ |      |         |     |
| fa    |              |          |        | _ |      |         |     |
| ther) |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | *    |         |     |
| whose |              | \        |        |   | *WHI |         |     |
| chi   |              | SISTERS' |        |   | TE** |         |     |
| ldren |              | AND      |        |   |      |         |     |
| does  |              | B        |        |   |      |         |     |
| this  |              | ROTHERS' |        |   |      |         |     |
| chart |              | CHART**  |        |   |      |         |     |
| ref   |              |          |        |   |      |         |     |
| er?** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **    |              |          |        |   |      |         |     |
|  / ** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *Moth |              |          |        |   |      |         |     |
| er\'s |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fath  |              |          |        |   |      |         |     |
| er\'s |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| S     | [(           |          | Yes No | \ |      | Name of | \   |
| ister |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| Br    | {.underline} |          | Type   | _ |      |         | _\_ |
| other |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
| Ha    | Middle       |          | Year   | \ |      | County  |     |
| lf-Br | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| (same | Address      |          | where  | \ |      | ysician | F   |
| mo    |              |          | dia    | _ |      | (if     | ILL |
| ther) | City State   |          | gnosed | \ |      | known)  | O   |
|       | Zip          |          |        | | |      |         | UT\ |
| Ha    |              |          | City   | \ |      |         | A   |
| lf-Br | Phone:       |          | State  | _ |      |         | [   |
| other | [            |          |        | \ |      |         | WHI |
|       |  (           |          |        | _ |      |         | TE] |
| (same |          ) ] |          |        | \ |      |         | {.u |
| fa    | {.underline} |          |        | _ |      |         | nde |
| ther) |              |          |        | \ |      |         | rli |
|       | Area Code    |          |        | _ |      |         | ne} |
| H     | Number       |          |        | \ |      |         | CH  |
| alf-S |              |          |        | _ |      |         | ART |
| ister | Date of      |          |        | \ |      |         | FOR |
|       | Birth:       |          |        | | |      |         | NIE |
| (same | MO           |          |        | \ |      |         | CES |
| mo    | \_\_\_\_\_\_ |          |        | _ |      |         | AND |
| ther) | DAY          |          |        | \ |      |         | NE  |
|       | \_\_\_\_\_\_ |          |        | _ |      |         | PHE |
| H     | YR           |          |        | \ |      |         | WS. |
| alf-S | \_\_\_\_\_\_ |          |        | _ |      |         |     |
| ister |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
| (same |              |          |        | \ |      |         |     |
| fa    |              |          |        | _ |      |         |     |
| ther) |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| S     | [(           |          | Yes No | \ |      | Name of | \   |
| ister |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| Br    | {.underline} |          | Type   | _ |      |         | _\_ |
| other |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
| Ha    | Middle       |          | Year   | \ |      | County  |     |
| lf-Br | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| (same | Address      |          | where  | \ |      | ysician | F   |
| mo    |              |          | dia    | _ |      | (if     | ILL |
| ther) | City State   |          | gnosed | \ |      | known)  | O   |
|       | Zip          |          |        | | |      |         | UT\ |
| Ha    |              |          | City   | \ |      |         | A   |
| lf-Br | Phone:       |          | State  | _ |      |         | [   |
| other | [            |          |        | \ |      |         | WHI |
|       |  (           |          |        | _ |      |         | TE] |
| (same |          ) ] |          |        | \ |      |         | {.u |
| fa    | {.underline} |          |        | _ |      |         | nde |
| ther) |              |          |        | \ |      |         | rli |
|       | Area Code    |          |        | _ |      |         | ne} |
| H     | Number       |          |        | \ |      |         | CH  |
| alf-S |              |          |        | _ |      |         | ART |
| ister | Date of      |          |        | \ |      |         | FOR |
|       | Birth:       |          |        | | |      |         | NIE |
| (same | MO           |          |        | \ |      |         | CES |
| mo    | \_\_\_\_\_\_ |          |        | _ |      |         | AND |
| ther) | DAY          |          |        | \ |      |         | NE  |
|       | \_\_\_\_\_\_ |          |        | _ |      |         | PHE |
| H     | YR           |          |        | \ |      |         | WS. |
| alf-S | \_\_\_\_\_\_ |          |        | _ |      |         |     |
| ister |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
| (same |              |          |        | \ |      |         |     |
| fa    |              |          |        | _ |      |         |     |
| ther) |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| S     | [(           |          | Yes No | \ |      | Name of | \   |
| ister |              |          | DK     | | |      | H       | _\_ |
|       |          ) ] |          |        | \ |      | ospital | \_\ |
| Br    | {.underline} |          | Type   | _ |      |         | _\_ |
| other |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
| Ha    | Middle       |          | Year   | \ |      | County  |     |
| lf-Br | Maiden       |          |        | _ |      | State   | Num |
| other |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
| (same | Address      |          | where  | \ |      | ysician | F   |
| mo    |              |          | dia    | _ |      | (if     | ILL |
| ther) | City State   |          | gnosed | \ |      | known)  | O   |
|       | Zip          |          |        | | |      |         | UT\ |
| Ha    |              |          | City   | \ |      |         | A   |
| lf-Br | Phone:       |          | State  | _ |      |         | [   |
| other | [            |          |        | \ |      |         | WHI |
|       |  (           |          |        | _ |      |         | TE] |
| (same |          ) ] |          |        | \ |      |         | {.u |
| fa    | {.underline} |          |        | _ |      |         | nde |
| ther) |              |          |        | \ |      |         | rli |
|       | Area Code    |          |        | _ |      |         | ne} |
| H     | Number       |          |        | \ |      |         | CH  |
| alf-S |              |          |        | _ |      |         | ART |
| ister | Date of      |          |        | \ |      |         | FOR |
|       | Birth:       |          |        | | |      |         | NIE |
| (same | MO           |          |        | \ |      |         | CES |
| mo    | \_\_\_\_\_\_ |          |        | _ |      |         | AND |
| ther) | DAY          |          |        | \ |      |         | NE  |
|       | \_\_\_\_\_\_ |          |        | _ |      |         | PHE |
| H     | YR           |          |        | \ |      |         | WS. |
| alf-S | \_\_\_\_\_\_ |          |        | _ |      |         |     |
| ister |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
| (same |              |          |        | \ |      |         |     |
| fa    |              |          |        | _ |      |         |     |
| ther) |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | *    |         |     |
| whose |              | \        |        |   | *WHI |         |     |
| chi   |              | NIECES'  |        |   | TE** |         |     |
| ldren |              | AND      |        |   |      |         |     |
| does  |              | NEPHEWS' |        |   |      |         |     |
| this  |              | CHART**  |        |   |      |         |     |
| chart |              |          |        |   |      |         |     |
| ref   |              |          |        |   |      |         |     |
| er?** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **    |              |          |        |   |      |         |     |
|  / ** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| niece | [(           |          | Yes No | \ |      | Name of | \   |
|       |              |          | DK     | | |      | H       | _\_ |
| n     |          ) ] |          |        | \ |      | ospital | \_\ |
| ephew | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician | *   |
|       |              |          | dia    | _ |      | (if     | *GO |
|       | City State   |          | gnosed | \ |      | known)  | B   |
|       | Zip          |          |        | | |      |         | ACK |
|       |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
|       | [            |          |        | \ |      |         | STI |
|       |  (           |          |        | _ |      |         | ONN |
|       |          ) ] |          |        | \ |      |         | AIR |
|       | {.underline} |          |        | _ |      |         | E** |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| niece | [(           |          | Yes No | \ |      | Name of | \   |
|       |              |          | DK     | | |      | H       | _\_ |
| n     |          ) ] |          |        | \ |      | ospital | \_\ |
| ephew | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician | *   |
|       |              |          | dia    | _ |      | (if     | *GO |
|       | City State   |          | gnosed | \ |      | known)  | B   |
|       | Zip          |          |        | | |      |         | ACK |
|       |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
|       | [            |          |        | \ |      |         | STI |
|       |  (           |          |        | _ |      |         | ONN |
|       |          ) ] |          |        | \ |      |         | AIR |
|       | {.underline} |          |        | _ |      |         | E** |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| niece | [(           |          | Yes No | \ |      | Name of | \   |
|       |              |          | DK     | | |      | H       | _\_ |
| n     |          ) ] |          |        | \ |      | ospital | \_\ |
| ephew | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician | *   |
|       |              |          | dia    | _ |      | (if     | *GO |
|       | City State   |          | gnosed | \ |      | known)  | B   |
|       | Zip          |          |        | | |      |         | ACK |
|       |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
|       | [            |          |        | \ |      |         | STI |
|       |  (           |          |        | _ |      |         | ONN |
|       |          ) ] |          |        | \ |      |         | AIR |
|       | {.underline} |          |        | _ |      |         | E** |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED MORE SPACE FOR NIECES AND NEPHEWS, USE THE OTHER SIDE OF
THIS CHART OR FILL OUT ANOTHER CHART FOR YOUR NIECES AND NEPHEWS. IF YOU
HAVE COMPLETED INFORMATION ON ALL OF YOUR NIECES AND NEPHEWS, GO BACK TO
THE QUESTIONNAIRE AND COMPLETE YOUR GRANDPARENTS' CHART.**

+-------+--------------+----------+--------+---+------+---------+-----+
| **To  |              | **\      |        |   | *    |         |     |
| whose |              | \        |        |   | *WHI |         |     |
| chi   |              | NIECES'  |        |   | TE** |         |     |
| ldren |              | AND      |        |   |      |         |     |
| does  |              | NEPHEWS' |        |   |      |         |     |
| this  |              | CHART**  |        |   |      |         |     |
| chart |              |          |        |   |      |         |     |
| ref   |              |          |        |   |      |         |     |
| er?** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **    |              |          |        |   |      |         |     |
|  / ** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| **Mot |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| Name  |              |          |        |   |      |         |     |
| Fat   |              |          |        |   |      |         |     |
| her's |              |          |        |   |      |         |     |
| N     |              |          |        |   |      |         |     |
| ame** |              |          |        |   |      |         |     |
|       |              |          |        |   |      |         |     |
| *     |              |          |        |   |      |         |     |
| *LIST |              |          |        |   |      |         |     |
| IN    |              |          |        |   |      |         |     |
| ORDER |              |          |        |   |      |         |     |
| OF    |              |          |        |   |      |         |     |
| BI    |              |          |        |   |      |         |     |
| RTH** |              |          |        |   |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| Rel   | Name, date   |          | Did    | A |      |         | How |
| ation | of birth     |          | this   | N |      |         | m   |
| ship\ | and, if      |          | person | S |      |         | any |
| to    | living,\     |          | ever\  | W |      |         | ch  |
| you   | address and  |          | have   | E |      |         | ild |
|       | phone number |          | c      | R |      |         | ren |
|       |              |          | ancer, | O |      |         | did |
|       |              |          | a      | N |      |         | t   |
|       |              |          | t      | L |      |         | his |
|       |              |          | umor,\ | Y |      |         | per |
|       |              |          | or a   | I |      |         | son |
|       |              |          | g      | F |      |         | ha  |
|       |              |          | rowth? | P |      |         | ve? |
|       |              |          |        | E |      |         |     |
|       |              |          |        | R |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | O |      |         |     |
|       |              |          |        | N |      |         |     |
|       |              |          |        | I |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | E |      |         |     |
|       |              |          |        | A |      |         |     |
|       |              |          |        | D |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
|       |              |          |        | D |      | H       |     |
|       |              |          |        | a |      | ospital |     |
|       |              |          |        | t |      | where   |     |
|       |              |          |        | e |      | died    |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | p |      |         |     |
|       |              |          |        | l |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | , |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | c |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | f |      |         |     |
|       |              |          |        | d |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| niece | [(           |          | Yes No | \ |      | Name of | \   |
|       |              |          | DK     | | |      | H       | _\_ |
| n     |          ) ] |          |        | \ |      | ospital | \_\ |
| ephew | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician | *   |
|       |              |          | dia    | _ |      | (if     | *GO |
|       | City State   |          | gnosed | \ |      | known)  | B   |
|       | Zip          |          |        | | |      |         | ACK |
|       |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
|       | [            |          |        | \ |      |         | STI |
|       |  (           |          |        | _ |      |         | ONN |
|       |          ) ] |          |        | \ |      |         | AIR |
|       | {.underline} |          |        | _ |      |         | E** |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| niece | [(           |          | Yes No | \ |      | Name of | \   |
|       |              |          | DK     | | |      | H       | _\_ |
| n     |          ) ] |          |        | \ |      | ospital | \_\ |
| ephew | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician | *   |
|       |              |          | dia    | _ |      | (if     | *GO |
|       | City State   |          | gnosed | \ |      | known)  | B   |
|       | Zip          |          |        | | |      |         | ACK |
|       |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
|       | [            |          |        | \ |      |         | STI |
|       |  (           |          |        | _ |      |         | ONN |
|       |          ) ] |          |        | \ |      |         | AIR |
|       | {.underline} |          |        | _ |      |         | E** |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+
| niece | [(           |          | Yes No | \ |      | Name of | \   |
|       |              |          | DK     | | |      | H       | _\_ |
| n     |          ) ] |          |        | \ |      | ospital | \_\ |
| ephew | {.underline} |          | Type   | _ |      |         | _\_ |
|       |              |          | or     | \ |      | City    | \_\ |
|       | Last First   |          | site   | _ |      |         | _\_ |
|       | Middle       |          | Year   | \ |      | County  |     |
|       | Maiden       |          |        | _ |      | State   | Num |
|       |              |          | Ho     | \ |      |         | ber |
|       | Street       |          | spital | _ |      | Ph      |     |
|       | Address      |          | where  | \ |      | ysician | *   |
|       |              |          | dia    | _ |      | (if     | *GO |
|       | City State   |          | gnosed | \ |      | known)  | B   |
|       | Zip          |          |        | | |      |         | ACK |
|       |              |          | City   | \ |      |         | TO  |
|       | Phone:       |          | State  | _ |      |         | QUE |
|       | [            |          |        | \ |      |         | STI |
|       |  (           |          |        | _ |      |         | ONN |
|       |          ) ] |          |        | \ |      |         | AIR |
|       | {.underline} |          |        | _ |      |         | E** |
|       |              |          |        | \ |      |         |     |
|       | Area Code    |          |        | _ |      |         |     |
|       | Number       |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       | Date of      |          |        | \ |      |         |     |
|       | Birth:       |          |        | | |      |         |     |
|       | MO           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | DAY          |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       | YR           |          |        | \ |      |         |     |
|       | \_\_\_\_\_\_ |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | _ |      |         |     |
|       |              |          |        | \ |      |         |     |
|       |              |          |        | | |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | M |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | h |      |         |     |
|       |              |          |        | D |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | Y |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | r |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | i |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | o |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | n |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | y |      |         |     |
|       |              |          |        | S |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | t |      |         |     |
|       |              |          |        | e |      |         |     |
|       |              |          |        |   |      |         |     |
|       |              |          |        | C |      |         |     |
|       |              |          |        | a |      |         |     |
|       |              |          |        | u |      |         |     |
|       |              |          |        | s |      |         |     |
|       |              |          |        | e |      |         |     |
+-------+--------------+----------+--------+---+------+---------+-----+

**IF YOU NEED MORE SPACE FOR NIECES AND NEPHEWS, USE THE OTHER SIDE OF
THIS CHART OR FILL OUT ANOTHER CHART FOR YOUR NIECES AND NEPHEWS. IF YOU
HAVE COMPLETED INFORMATION ON ALL OF YOUR NIECES AND NEPHEWS, GO BACK TO
THE QUESTIONNAIRE AND COMPLETE YOUR GRANDPARENTS' CHART.**