| Certificate Number | 22 | | Date Issued |
| Child Given Name | Henry M. |
Templeton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Oct 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | H.M. |
Templeton | Father's Surname |
| Father's Birth Place | Ohio | 40 | 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 | | Bethel VT | Mother's Birth Place |
| Mother's Age | 38 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Templeton | Ames IA | Medical Attendant's Address |