| Certificate Number | 370 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Story City Story Co IA | Place of Birth |
| Father's Given Name | Americus |
Smith | Father's Surname |
| Father's Occupation | Painter | | Father's Nationality |
| Father's Birth Place | Denmark | 25 | Father's Age |
| Mother's Given Name | Christena | Christianson | Mother's Maiden Name |
| Mother's Surname | Smith | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |