| Certificate Number | 192 | | Date Issued |
| Child Given Name | Clarence Albert |
Wembly | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Nov 1885 |
Ontario Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Wembly | Father's Surname |
| Father's Occupation | Agent | | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Mattie | Hendrickson | Mother's Maiden Name |
| Mother's Surname | Wembly | Ontario Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 22 | | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |