| Certificate Number | 763 | | Date Issued |
| Child Given Name | |
Miller | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Jul 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Miller | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Mother's Given Name | Mary | Elliott | Mother's Maiden Name |
| Mother's Surname | Miller | Ames Story Co IA | Mother's Residence |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |