| Certificate Number | 507 | | Date Issued |
| Child Given Name | |
Burgess | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Feb 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | A.E. |
Burgess | Father's Surname |
| Father's Occupation | Creamer | | Father's Nationality |
| Father's Birth Place | Illinois | 28 | Father's Age |
| Mother's Given Name | Emma G. | Carr | Mother's Maiden Name |
| Mother's Surname | Burgess | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |