| Certificate Number | 628 | | Date Issued |
| Child Given Name | Mary A. |
Templeton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Aug 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Henry M. |
Templeton | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Ohio | 39 | Father's Age |
| Mother's Given Name | Edna | Granger | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Vermont | Mother's Birth Place |
| Mother's Age | 37 | 3 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |