| Certificate Number | 949 | | Date Issued |
| Child Given Name | John Witman Seepage |
Beard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 May 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John |
Beard | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Susie | Brown | Mother's Maiden Name |
| Mother's Surname | Beard | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 15 | | Number of Child This Mother |
| Medical Attendant's Name | J.T. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.T. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.T. Bartlett | | |