| Certificate Number | 384 | | Date Issued |
| Child Given Name | |
Rice | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 16 May 1882 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Carter |
Rice | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Indiana | 25 | Father's Age |
| Mother's Given Name | Annie | Maxwell | Mother's Maiden Name |
| Mother's Surname | Rice | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 2 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merrideth M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merrideth M.D. | | Certificate Signer's Address |
| Returned by Name | G.A. Merrideth M.D. | | |