| Certificate Number | 317 | | Date Issued |
| Child Given Name | |
Robinson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 May 1886 |
Onondago St Ames Story Co IA | Place of Birth |
| Father's Given Name | George |
Robinson | Father's Surname |
| Father's Occupation | Gun Smith | | Father's Nationality |
| Father's Birth Place | Denmark | 28 | Father's Age |
| Mother's Given Name | Anna | Johnson | Mother's Maiden Name |
| Mother's Surname | Robinson | Onondago St Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Petra Peterson | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |