| Child Given Name | Earl Clifford |
Belt | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Apr 1887 |
Collins, Story Co IA | Place of Birth |
| Father's Given Name | George Washington |
Belt | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Iowa | 32 | Father's Age |
| Mother's Given Name | Mary Emily | Holtsclaw | Mother's Maiden Name |
| Mother's Surname | | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 30 | 1 | Number of Child This Mother |
| Medical Attendant's Name | N.W., Dr. Knepper | Collins IA | Medical Attendant's Address |