| Certificate Number | 701 | | Date Issued |
| Child Given Name | |
McCarthy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jul 1883 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Willard F. |
McCarthy | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Mary Ida | Spence | Mother's Maiden Name |
| Mother's Surname | McCarthy | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.S. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.S. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.S. Bartlett | | |