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| # | Question | Answer |
| Serial Number | 2965 | |
| Order Number | 1785 | |
| 1 | Name | Waddell W. Keith |
| 2 | Address | 6534 S Aberdeen St, Chicago, Ill. |
| 3 | Telephone | (blank) |
| 4 | Age in Years, Date of Birth | 21, Feb 21 1919 |
| 5 | Place of Birth | Chicago |
| 6 | Country of Citizenship | Cook – USA |
| 7 | Name of person who will always know your address. | Mrs. Leota Keith |
| 8 | Relationship to the Person | sister |
| 9 | Address of the Person | 6534 S Aberdeen St, Chicago, Cook, Ill |
| 10 | Employers Name | Wallace Bros Shows |
| 11 | Place of Employment or Business | Travelers |
| (signature) | Waddell W, Keith | |
| R1 | Race | Negro |
| R2 | Height | 6′ 1/4″ |
| R3 | Weight | 157 |
| R4 | Complexion | light brown |
| R5 | Eyes | brown |
| R6 | Hair | brown |
| R7 | Other obvious physical characteristic that will aid in identification: | (blank) |
| R8 | I certify that my answers are true; that the person registered has read or has had read to him his own answers; that I have witnessed his signature or mark and that all of his answers of which I have knowledge are true, except as follows: | (blank) |
| (signature of registrar) | R. D. Calhoun | |
| Registrar for: | Shady Grove School | |
| Date of Registration | Oct 16 – 1940 | |
| Stamp of Board (No and address) | Chicago Board No 104, 1834 West 59th St, Chicago, Cook Co., Illinois. |
