| Certificate Number | 395 | | Date Issued |
| Child Given Name | |
Patterson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Sep 1886 |
Kellogg St Ames Story Co IA | Place of Birth |
| Father's Given Name | Elza |
Patterson | Father's Surname |
| Father's Occupation | Stone Mason | | Father's Nationality |
| Father's Birth Place | Cambridge OH | 36 | Father's Age |
| Mother's Given Name | Marcella | Osborne | Mother's Maiden Name |
| Mother's Surname | Patterson | Kellogg St Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Lima Allen Co OH | Mother's Birth Place |
| Mother's Age | 31 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Frank, Mrs. Watson | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |