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