| Certificate Number | 260 | | Date Issued |
| Child Given Name | |
Bayley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Oct 1881 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Jno M. |
Bayley | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Kentucky | 30 | Father's Age |
| Mother's Given Name | Emma Jane | | Mother's Maiden Name |
| Mother's Surname | Bayley | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.M. Palmer | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | C.M. Palmer | Story City IA | Certificate Signer's Address |
| Returned by Name | C.M. Palmer | | |