| Certificate Number | 595 | | Date Issued |
| Child Given Name | Thomas |
Bates | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Jan 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Sylvester |
Bates | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Michigan | 24 | Father's Age |
| Mother's Given Name | Betty J. | Harrison | Mother's Maiden Name |
| Mother's Surname | Bates | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |