| Certificate Number | 766 | | Date Issued |
| Child Given Name | |
McCall | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Jan 1883 |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | Rev. |
McCall | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | | 40 | Father's Age |
| Mother's Surname | McCall | Gilbert Story Co IA | Mother's Residence |
| Mother's Age | 40 | 4 | 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 | | |