| Certificate Number | 21 | | Date Issued |
| Child Given Name | |
Templeton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Nov 1888 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | M.W. |
Templeton | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 36 | Father's Age |
| Mother's Given Name | Hellen M. | Lewis | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 33 | 3 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |