| Child Given Name | John Samuel |
Jones | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Nov 1877 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | James Madison |
Jones | Father's Surname |
| Father's Occupation | Farmer | Ohio | Father's Nationality |
| Father's Birth Place | Ohio | 24 | Father's Age |
| Mother's Given Name | Lucinda Frances | Marsh | Mother's Maiden Name |
| Mother's Surname | Jones | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Certificate Signer's Name | Martha King | | Certificate Signer's Address |