| Certificate Number | 681 | | Date Issued |
| Child Given Name | |
Stamp | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Jun 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Isaac |
Stamp | Father's Surname |
| Father's Occupation | Laborer | English | Father's Nationality |
| Father's Birth Place | New York | 26 | Father's Age |
| Mother's Given Name | Nellie | Beaumont | Mother's Maiden Name |
| Mother's Surname | Stamp | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | English | New York | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |