| Certificate Number | 86 | | Date Issued |
| Child Given Name | |
Merrick | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Dec 1889 |
Ontario Story Co IA | Place of Birth |
| Father's Given Name | Alton C. |
Merrick | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Maine | 36 | Father's Age |
| Mother's Given Name | Carrie | Lyon | Mother's Maiden Name |
| Mother's Surname | | Ontario Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |