| Certificate Number | 371 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 30 Mar 1882 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm. T. |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 26 | Father's Age |
| Mother's Given Name | Minnie E. | Williams | Mother's Maiden Name |
| Mother's Surname | Scott | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.H. Merrideth | | Medical Attendant's Address |
| Certificate Signer's Name | G.H. Merrideth | | Certificate Signer's Address |
| Returned by Name | G.H. Merrideth | | |