| Certificate Number | 75 | | Date Issued |
| Child Given Name | |
Spencer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Nov 1880 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
Spencer | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | Nellie | Bryant | Mother's Maiden Name |
| Mother's Surname | Spencer | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | James Bradly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | James Bradly | Ames IA | Certificate Signer's Address |
| Returned by Name | James Bradly | | |