| Certificate Number | 206 | | Date Issued |
| Child Given Name | Rush M. |
Templeton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Sep 1885 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Prosper J. |
Templeton | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Malinda | Smith | Mother's Maiden Name |
| Mother's Surname | Templeton | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton M.D. | | |