| Certificate Number | 849 | | Date Issued |
| Child Given Name | Clarance Ernie |
Bates | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jan 1884 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | H.W. |
Bates | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Michigan | 30 | Father's Age |
| Mother's Given Name | Anna Etta | Edgett | Mother's Maiden Name |
| Mother's Surname | Bates | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo Stitzell | | |