INSTRUCTION: Unless this history is accompanied by a social case history and would therefore duplicate information contained therein, this blank must be filled out completely , with ink or typewriter.  DO NOT LEAVE ANY SPACES BLANK.  If information cannot be obtained or is given elsewhere so indicate.
   Where admission of several children of the same father and mother is being sought, a complete history need be filled out only on the oldest child.  For the younger children fill out only sections I, VI, and VIII, and note on whose sheet the complete history will be found.  This does not apply to children of the same mother and different fathers or the reverse.
   This application must be accompanied by a birth certificate for the child; or a statement from the Bureau of Vital Statistics showing that the birth was not registered PLUS some legally acceptable statement of the child's birth date.
 
I. BROTHERS AND SISTERS OF CHILD           Mark with star names of those for whom admission is also being sought.
 
 Name              Full, step    Date & Place --- - School Grade, or Mentally or Physically--- -Address If Living ---- Sex
                        Half, Illeg.     of  Birth              or Occupation              Defective               If dead ,date & cause
*Jimmie Dale   Full       6/24/36                  Kindg.                          No                       2340 E. 9th                M
                                       Ames, Iowa                                                                              Des Moines
 
 Juanita Fry     Half       5/8/30                        5th                              No                        Nevada                    F
                                       Ames, Iowa
 
II.  PARENTS                                         FATHER                                        MOTHER
 
Sources of Information                                  Story County Records & Juvenile Court Records

FULL NAME                                          Floyd Peterson                         Sylvia Peterson Leifheit                  
Last Known Address if Living                   Deceased                                   2033 4th Ave. Rock Island, Ill.         
Length of Residence in State, County        Life                                               Life
Date and Place of birth                             Ames, Iowa, Sept. 16, 1909    Collins, Iowa, April 30, 1912           
Nationality, Descent and Creed                American -- Protestant               American -- Lutheran                     
Completed what grade at what age?         8th -- average                               8th -- average                                    
Good, Average or Poor Student
 
Date and Place of Marriage                      May 6, 1933, Des Moines        May 6, 1933 Des Moines                      
Previous Marriages                                 -----                                                Virgil Fry, Bethany, Missouri                 
If Ever Divorced, Date and Causes           -----                                             Dec. 7, 1932 Cruel,inhuman treatment
Work Record, Occupation and Income     -----                                                Fair -- clerk, income unknown        
Employer                                                  -----                                               Woolworth                                           
If at Any Time a Soldier or Sailor              -----                                                -----                                                        
Physically Defective                                  No                                                No                                                           
Venereal History                                       -----                                              No                                                            
Mentally or Morally Defective                   -----                                               Morally defective                                 
Temperate                                                -----                                               Intemperate                                           
Gambling Habit
Jail or Prison Sentence Charge and Date                                                        None                                                      
Inmate of Any Other Institution                                                                       No                                                            
If Dead, Place, Date, Cause                     Ames, 1/28/39, Trench Mouth                                                                  
 
 
Color of Hair and Eyes, Complexion,                                                              Brown hair & eyes, fair complexion
Height, Weight, General Physical Build                                                            5'  5" 120# small in Stature                
and Appearance                                                                                             Careless about personal appearance

Paternal family:

 Housewife
Laborer                                       Good  None                                          Unknown
Farmer                                               "    "                                                          "
Laborer                                              "    "                                                          "
-----
-----
 
 
 
Maternal family:

WPA                8th                             Good                 -------                     Favorable
Housewife     5th                  Fair  Very nervous                                           "
Plumber         8th                  Good  None                                                       "
   "         "          "                             "                                                                    "
----                     ---                     Fair                                          Drinks excessively   Receives blind pension
----                    12th                        "                           Psychopathic.   Fair, treated at Psychopathic Hosp.
 
What is the reputation of the family as whole in the community?  What members, if any, are exceptions to the family general reputation?
 
MATERNAL
 
 

IV.  In order to avoid any future difficulties over relatives seeking the child after he may have bee placed in a foster home,
indicate here for each adult married relative the following --- whether he or she has been contacted regarding taking the
child and what his or her attitude is toward this, or why such contact was not made.  This may be omitted in the case of a
young illegitimate child.
 
 
        Relatives are aware that children will be placed.
 
 
 
 
V.  State here the situation and circumstances in regard to the child's parents which make it imperative that the child be
removed from their custody permanently.
 
 

On June 28, 1940, a complaint was filed by the County Attorney charging
the mother with disorderly conduct and drinking excessively.  It also
charged that the children were dependent and neglected.  July 5, 1940,
the mother of Larry & Jimmie appeared in Juvenile Court with them, and
admitted that they were dependent and neglected and that she was unable
to care for them.  It was therefor ordered and adjudged that they be
placed in the care, custody and control of the Iowa Children's Home
Society at Des Moines, Iowa.  The children were placed there and are
there at this time.  In the past the mother was permitted to visit them
in their foster homes, but from time to time she would visit these homes
when she was intoxicated and it became necessary to withdraw this
privilege.  Later the mother married Edward Leifheit and took up
residence in Rock Island, Illinois.  They live over a tavern, the mother
works at Woolworths' and buys her meals in a cafe.  Her present husband
has been an inmate at the Reformatory in Anamosa, Iowa, and her brother-
in-law has been arrested on a charge of burglary.  Their  adjustment in
the foster homes have been quite unfavorable.  Dr. Habenicht states
"that both these children are badly in need of long time routinized
training such as is given in an institution.  It has been a long and
difficult task to correct these children -- when they entered their foster
homes they were completely untrained in habits of cleanliness and eating
habits."  Due to the several factors involved, it has been ordered by
the Juvenile Court that they be placed in the Soldiers Orphanage at
Davenport, Iowa.

VII.  Medical, Health, and Developmental History
 
    Birth -- Full time.  Yes   or          months.                   Weight              7#        Natural     Yes                  Instrumental.
 
    Attending physician.                           None
 
    Any unusual circumstances as prolonged and difficult labor, breech presentation, attempted abortion, etc.
 
 
 
         Diseases and illnesses -- Mention all childhood and contagious diseases, and any other serious illnesses, with
approximate dates.
                                                                Whooping cough, measles
 
 
    Feeding -- Breast or bottle.       Bottle
 
    At age of -- Sitting up alone      8 months.   Walking   14 months.  Talking    2 years.   Teething   6 months.
 
    Wassermann -- Give date and results:   Mother                                                              Child

     Is the child physically defective or handicapped in any way?       No.
 
 
    Present general physical condition.                 Good
 
 
 VIII.   Educational History
 
      Entered preschool at                                           years,  attended                                             years.
 
      Entered Kindergarten at                              5      years,  attended                                               years.
 
      Entered first grade at                                   6      years.
 
      What grades were repeated and how many times?
 
      Type of school attended, rural or graded?
 
      Has school attendance been generally regular or irregular?
 
      Is he considered a dull, average or bright student?    average
 
      Has he been well behaved or troublesome?
 
 
IX.   Person, persons or agency making this report.
   Story County Welfare Department,      H. H. Ver Ney                 Date  Jan. 14, 1942
 
X. Committed to Iowa Soldiers' Orphans' Home.   Davenport, Iowa.            Accepted   Jan. 27, 1942