| Certificate Number | 1029 | | Date Issued |
| Child Given Name | |
Richards | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Jul 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | J. |
Richards | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | | 30 | Father's Age |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |