| Child Given Name | Clyde Dernier |
Hall | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Apr 1889 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Franklin Lee |
Hall | Father's Surname |
| Father's Occupation | | American | Father's Nationality |
| Father's Birth Place | Maxwell Story Co IA | 27 | Father's Age |
| Mother's Given Name | Clara Lourinda | John | Mother's Maiden Name |
| Mother's Nationality | American | Maxwell Story Co IA | Mother's Birth Place |
| Mother's Age | 27 | | Number of Child This Mother |
| Medical Attendant's Name | P., Dr. Joor | | Medical Attendant's Address |
| Returned by Name | Alice Hall Wood | | |