| Certificate Number | 314 | | Date Issued |
| Child Given Name | Clarence |
Miller | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Aug 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | T.C. |
Miller | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Mary | Elliott | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |