(image 539 is companion to image 538)
Reported by...
Date...
Eugenics Record Office
Cold Spring Harbor, Long Island, N.Y.
Record of Individual Case of Sterilization
Full name...
(no names will be published in the report. In case of married women record both maiden and married name)
Birthplace...Residences...
Present Address...
Sex...Age when operated upon...
Date of operation...Surgeon...
(name) (address)
Reason for operation...
With or without the consent of the individual or his or her family...
If voluntary, give motive for application...
Type of operation...
(Record also sterilization thru medical necessity and by accident)
Medical, physiological, psychopathic, criminal, social, sex, and economic history of case before and after sterilization. Immediate and remote effects. Attitude of individual toward his sterilization...