| Certificate Number | 1031 | | Date Issued |
| Child Given Name | Clarence Albert |
Spohn | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Oct 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Daniel |
Spohn | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 30 | Father's Age |
| Mother's Given Name | Anna | Coe | Mother's Maiden Name |
| Mother's Surname | Spohn | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 5 | Number of Child This Mother |
| Medical Attendant's Name | C.A., Dr. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A., Dr. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A., Dr. Beverly | | |