| Certificate Number | 311 | | Date Issued |
| Child Given Name | John W. |
Wilson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Oct 1888 |
Kelley Story Co IA | Place of Birth |
| Father's Given Name | Lars J. |
Wilson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 25 | Father's Age |
| Mother's Given Name | Tillie | Larson | Mother's Maiden Name |
| Mother's Surname | | Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |