| Certificate Number | 84 | | Date Issued |
| Child Given Name | |
Norris | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Mar 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John S. |
Norris | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Isle of Wight England | 40 | Father's Age |
| Mother's Given Name | Elizabeth A. | Hurd | Mother's Maiden Name |
| Mother's Surname | Norris | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Onondago Canada | Mother's Birth Place |
| Mother's Age | 40 | 7 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |