| Certificate Number | 196 | | Date Issued |
| Child Given Name | Marcellus |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Feb 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Marcellus K. |
Smith | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | | 29 | Father's Age |
| Mother's Given Name | Laura | West | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |