| Certificate Number | 214 | | Date Issued |
| Child Given Name | Alice |
Watts | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Apr 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John |
Watts | Father's Surname |
| Father's Occupation | Postmaster | | Father's Nationality |
| Father's Birth Place | New York | 39 | Father's Age |
| Mother's Given Name | Alice E. | Cook | Mother's Maiden Name |
| Mother's Surname | Watts | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 32 | 6 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |