| Certificate Number | 213 | | Date Issued |
| Child Given Name | |
Wells | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Aug 1890 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Jas D. |
Wells | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Michigan | 41 | Father's Age |
| Mother's Given Name | Lillian E. | Stewart | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Michigan | Mother's Birth Place |
| Mother's Age | 41 | 7 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |