| Certificate Number | 403 | | Date Issued |
| Child Given Name | Bernice Merwin |
Soper | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Oct 1886 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Chas. M. |
Soper | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | New York | 32 | Father's Age |
| Mother's Given Name | Ella M. | Underwood | Mother's Maiden Name |
| Mother's Surname | Soper | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb | | |