| Certificate Number | 754 | | Date Issued |
| Child Given Name | |
Stuart | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Feb 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Chas |
Stuart | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Mother's Given Name | | Elliott | Mother's Maiden Name |
| Mother's Surname | Stuart | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |