| Certificate Number | 12 | | Date Issued |
| Child Given Name | |
Sills | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Oct 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm. |
Sills | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | in | 22 | Father's Age |
| Mother's Given Name | Mary E. | Stoop | Mother's Maiden Name |
| Mother's Surname | Sills | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Missouri | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |