| Certificate Number | 217 | | Date Issued |
| Child Given Name | |
Person | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Jun 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Alba H. |
Person | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Iowa | 31 | Father's Age |
| Mother's Given Name | Jennie | Reynolds | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 30 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |