| Certificate Number | 368 | | Date Issued |
| Child Given Name | Clyde Earl |
Slaughter | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 22 Mar 1882 |
Gilbert Station Story Co IA | Place of Birth |
| Father's Given Name | Thomas Jefferson |
Slaughter | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 28 | Father's Age |
| Mother's Given Name | H. Elizabeth | | Mother's Maiden Name |
| Mother's Surname | Slaughter | Gilbert Station Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 36 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Rachel Marshall | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | Rachel Marshall | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | Rachel Marshall | | |