| Certificate Number | 140 | | Date Issued |
| Child Given Name | James S. |
Sanders | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jun 1885 |
Story Co IA | Place of Birth |
| Father's Given Name | James F. |
Sanders | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 46 | Father's Age |
| Mother's Given Name | Perlie | Booth | Mother's Maiden Name |
| Mother's Surname | Sanders | Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 36 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Abbey M. Penn | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Abbey M. Penn | Nevada IA | Certificate Signer's Address |
| Returned by Name | Abbey M. Penn | | |