| Certificate Number | 116 | | Date Issued |
| Child Given Name | Clyde |
Bullock | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 May 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | E.A. |
Bullock | Father's Surname |
| Father's Occupation | | American | Father's Nationality |
| Father's Birth Place | Iowa | 22 | Father's Age |
| Mother's Given Name | Minnie | Johnston | Mother's Maiden Name |
| Mother's Surname | Bullock | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jas. Bradley | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | Jas. Bradley | Ames IA | Certificate Signer's Address |
| Returned by Name | Jas. Bradley | | |