| Certificate Number | 204 | | Date Issued |
| Child Given Name | |
Sims | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Sep 1890 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | M.F. |
Sims | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 30 | Father's Age |
| Mother's Given Name | Annabelle | Finch | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Albert Richmond | Ames IA | Medical Attendant's Address |