| Certificate Number | 942 | | Date Issued |
| Child Given Name | Frank |
Van Petter | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 May 1884 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Orlando |
Van Patter | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 36 | Father's Age |
| Mother's Given Name | Mariah | Stevens | Mother's Maiden Name |
| Mother's Surname | Van Patter | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 44 | 6 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |