| Decedent's Given Name | May |
unknown | Decedent's Surname |
| Location | Ames |
207 | Enumeration District |
| Enumerator | E.R. Chamberlain |
S.S | Family Number |
| Age | |
F | Sex |
| Color | W |
Single | Marital Status |
| Birth Place | New York |
| Father's Birth Place |
| Mother's Birth Place | |
| Occupation |
| Month of Death | Aug |
Diptheria | Cause of Death |
| How long in Story Co. | |
| Where illness contracted |
| Attending Physician | |
| Physician's Statement - Primary Cause |
| Physician's Statement - Immediate Cause | |
| Physician's Signature |
| Enumerator Remarks: | |
The following is not taken from the schedule. See the introduction for an explanation of sources.
| Birth Date | |
| Death Date |
| Head of Household Given Name | |
| Head of Household Surname |
| Grave Marker in Story Co.? | |
| Cemetery |
| Grave Marker Information: | |
| Transcriber Comments: | Surname unreadable. Age unreadable. |