| Certificate Number | 82 | | Date Issued |
| Child Given Name | |
Van Scoy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Feb 1885 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Van Scoy | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Dayton OH | 28 | Father's Age |
| Mother's Given Name | Matilda | Sherman | Mother's Maiden Name |
| Mother's Surname | Van Scoy | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Putnam Co IL | Mother's Birth Place |
| Mother's Age | 24 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton M.D. | | |