| Certificate Number | 280 | | Date Issued |
| Child Given Name | |
Quick | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Feb 1886 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Milton W. |
Quick | Father's Surname |
| Father's Occupation | Constable | | Father's Nationality |
| Father's Birth Place | Gainsville NY | 37 | Father's Age |
| Mother's Given Name | Katherine | Stamp | Mother's Maiden Name |
| Mother's Surname | Quick | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Lincolnshire England | Mother's Birth Place |
| Mother's Age | | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |