| Certificate Number | 189 | | Date Issued |
| Child Given Name | Herby Delbert |
Bates | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Sep 1885 |
Walnut Grove | Place of Birth |
| Father's Given Name | Thom |
Bates | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Michigan | 27 | Father's Age |
| Mother's Given Name | Arminda | Womack | Mother's Maiden Name |
| Mother's Surname | Bates | Walnut Grove | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb M.D. | | |