| Certificate Number | 815 | | Date Issued |
| Child Given Name | |
Stemily | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Stemily | Father's Surname |
| Father's Occupation | Farmer | German | Father's Nationality |
| Father's Birth Place | Germany | 23 | Father's Age |
| Mother's Given Name | Alley | Bates | Mother's Maiden Name |
| Mother's Surname | Stemily | 1 1/2 Mile N. of Elwell | Mother's Residence |
| Mother's Nationality | American | Story Co IA | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.R. Myers | | Medical Attendant's Address |
| Certificate Signer's Name | J.R. Myers | | Certificate Signer's Address |
| Returned by Name | J.R. Myers | | |