| Certificate Number | 254 | | Date Issued |
| Child Given Name | Chelsen |
Ruth | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Jan 1882 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Ruth | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Minerva | Kozier | Mother's Maiden Name |
| Mother's Surname | Ruth | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.F. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.F. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.F. Fairchild | | |