| Certificate Number | 140 | | Date Issued |
| Child Given Name | |
Stevens | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Mar 1888 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Carl C. |
Stevenson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 37 | Father's Age |
| Mother's Given Name | Florence | Gossard | Mother's Maiden Name |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |