| Certificate Number | 290 | | Date Issued |
| Child Given Name | |
Spencer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Feb 1886 |
| Place of Birth |
| Father's Given Name | Geo. H. |
Spencer | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Allie | Bryant | Mother's Maiden Name |
| Mother's Surname | Spencer | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 25 | 3 | 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 | | |