| Certificate Number | 762 | | Date Issued |
| Child Given Name | Howard Dalton |
Palmer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 May 1883 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Palmer | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 26 | Father's Age |
| Mother's Given Name | Elma | Ruth | Mother's Maiden Name |
| Mother's Surname | Palmer | Story City Story Co IA | Mother's Residence |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |