Question.

Yourself.

Christian name and surname of your father and your mother.

Designation & principal scientific titles of?

Darwin, Charles Robert Esqr. M.A. F.G.S. – F.L.S. – Hon. F.R.S.E. & M.R.I.A. Ord. Boruss. "Pour la Merite" Eq: Acadd. Imp. Reg. Sci. Vindob. Reg. Sci. Brux. et Soc. Asiat. Beng. Corresp. Acadd. Imp. Sci. Petrop. Reg. Sci. Berol. et Holm. Soc. Reg. Sci. Upsal. Acad. Caes. Nat.-Cur. Dresd. Soc. Sci. Neoc. et Acad. Nat. Sci. Philad. Soc. Honor.  

Down, Beckenham, Kent.

Your father and your mother are they respectively, English, Welsh Scotch Irish Jewish or foreign? If foreign of what country?

(Make no entry in this space.)

 " "  " wholly or in what degree?

( ditto )

Was either your father or your mother descended from persons persecuted for political or religious opinions, or from political or religious refugees? If so state the precise relationship – mention whether their political or religious opinions became traditional in the family?

(Make reply in this space to the last paragraph only of question).

Date of the birth?

1809.

Place of the birth of: (if you do not remember that of either your father or mother, state where he or she resided in early life).

Occupation or profession of?

Your Father.

Your Mother

Robert Waring Darwin M.D. F.R.S.

Enter here your mothers maiden name} Susanna Wedgwood.

The entry here is to refer to the father of your mother} Josiah Wedgwood Manufacturer

English.

English.

Wholly.

Wholly.

No.

No.

May 30th 1766.

Lichfied.

Etruria Staffordshire.

Physician

The entry here is to refer to the father of your mother. } Manufacturer of Pottery.