| Certificate Number | 652 | | Date Issued |
| Child Given Name | |
Brown | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 May 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Oliver |
Brown | Father's Surname |
| Father's Occupation | Bridge Builder | American | Father's Nationality |
| Father's Birth Place | Iowa | 22 | Father's Age |
| Mother's Given Name | Ada | Clothier | Mother's Maiden Name |
| Mother's Surname | Brown | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merridith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merridith | | |