| Certificate Number | 806 | | Date Issued |
| Child Given Name | Geo Carlyle |
Shockley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Oct 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Jacob A. |
Shockley | Father's Surname |
| Father's Occupation | R.R. Night Baggage man | American | Father's Nationality |
| Father's Birth Place | Indiana | 38 | Father's Age |
| Mother's Given Name | Juliette R. | Baldwin | Mother's Maiden Name |
| Mother's Surname | Schockley | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 9 | 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 | | |