Form of Application for Admission of a Child Into Connie Maxwell Orphanage At Greenwood, S.C. I. CERTIFICATE OF RELATIVE OR FRIEND Name of Child: Clyde Clayton Stukes Boy or Girl: Boy Date of birth: Nov 25, 1909 Place of birth: Jordan Is the child of legitimate birth: Yes Truthful? Yes Honest? Yes Addicted to any vicious habits? No How far advanced is the child in scholastic education? 5th grade Father's name: Thos. J. Stukes, Sr. Place of birth: Davis Station, SC Date of birth: July 18th, 1873 Moral Character: Good Was he temperate? Yes Died of what disease? Heart Trouble When? May 20th 1920 Where? Manning, SC Mother's name: Maude M. Stukes Maiden name: Maude M Reddick Place of birth: St. Stephens, SC Date of birth: Nov 15th 1880 Moral Character: Good Died of what disease? Child Birth When? Nov 2nd 1920 Where? Manning Is the child heir to any property? No If so, about what is its value __________ Who has charge of the property? ____ Name of legal guardian, if any _________ Was the father a member of any secret order? No If so, what? _________ If either parent is living, but unable to support child, state why. (If it a case of mental or physical inability send a certificate as to condition and cause by some reputable physician.) ________ I bear witness to the fact that the answers given above are true and accurate to the best of my knowledge and believe and that I sustain to this child the relation of : Brother (signed) Thos. J. Stukes, Jr. Date: Dec 14, 1920 Address: Manning, SC FAMILY RECORD Age Condition of Health Age Cause of Death How long ill Details Prev Health (living) (death) ----------------------------------------------------------------------------------------------------------- Father - - 46 Heart Trouble died suddenly - Pretty good Mother - - 40 Child Birth about 8 mo. - Poor Brothers 22 good Sisters 20 good 13 good Age attained by Grandparents: Father's father-ca.50 Father's mother-ca.50 Mother's father-ca.60 Mother's mother-ca 50 II. CERTIFICATE OF PASTOR (Or of other church officer in case the church has no pastor) Was the father of above-named child known to you? Yes What was his relation to the church? Member of Methodist Church. Was the mother known to you? Yes What was her relation to the church? Member of Methodist Church. What is the child's church relationship? Member Bap. Ch. Do you believe the child to be destitute and worthy of aid? Yes Do you regard the child as reasonably bright and capable of receiving an education? Yes (handwritten) While Mrs. Stukes was a member of the Methodist Church, she was a Baptist at heart and all the children are Baptist. (Signed) J. A. Easley, Jr. Pastor Manning Baptist Church Address: Manning S. C. III. CERTIFICATE OF PHYSICIAN Has the above-named child diseased scalp? No Scrofulous sores? No Sore eyes? No Any skin disease? If so, what? No Defective hearing? No Defective vision? No Defective speech? No Epilepsy? No Syphilis? No Idiocy? No. Feeble-mindedness? No Weak heart? No Kidney trouble? No Enlargement of liver? No Tuberculosis? No Catarrh? No Has the child had measles? Yes Mumps? No Small pox? No Scarlet fever? No Whooping cough? Yes Diphtheria? No Has child been successfully vaccinated? Yes Any deformity? No Evidence of evil results from any disease? No (signed) W. M. B???ki???, MD Address Manning, SC