| Certificate Number | 707 | | Date Issued |
| Child Given Name | |
Sleppy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Jul 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Aaron |
Sleppy | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 30 | Father's Age |
| Mother's Given Name | Rose A. | Martly | Mother's Maiden Name |
| Mother's Surname | Sleppy | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 38 | 4 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merrideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merrideth | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merrideth | | |