| Certificate Number | 155 | | Date Issued |
| Child Given Name | Fredrick S. |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 May 1890 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | W.H. |
Smith | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Ohio | 37 | Father's Age |
| Mother's Given Name | Martha | Larson | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 35 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Jane L. Bartlett | Ames IA | Medical Attendant's Address |