| Certificate Number | 281 | | Date Issued |
| Child Given Name | Joseph Larison |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Jan 1886 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm. Henry |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Cincinnati OH | 33 | Father's Age |
| Mother's Given Name | Martha | Larson | Mother's Maiden Name |
| Mother's Surname | Smith | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Vingen Norway | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |