| Certificate Number | 960 | | Date Issued |
| Child Given Name | Carl Henry |
Banks | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Jun 1884 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Henry |
Banks | Father's Surname |
| Father's Occupation | Farmer | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 34 | Father's Age |
| Mother's Given Name | Amanda | Taylor | Mother's Maiden Name |
| Mother's Surname | Banks | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merridith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merridith | | |