| Certificate Number | 959 | | Date Issued |
| Child Given Name | |
Round | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jun 1884 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Chester |
Round | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Mary E. | Bonebrake | Mother's Maiden Name |
| Mother's Surname | Round | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merrideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merrideth | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merrideth | | |