| Certificate Number | 394 | | Date Issued |
| Child Given Name | |
Myers | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Sep 1886 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Joseph |
Myers | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Elizabeth IN | 27 | Father's Age |
| Mother's Given Name | Ervina | Phillips | Mother's Maiden Name |
| Mother's Surname | Myers | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Boone KY | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Agatha, Mrs. Caldine | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |