| Certificate Number | 149 | | Date Issued |
| Child Given Name | |
Young | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 18 Mar 1881 |
Boone Co IA | Place of Birth |
| Father's Given Name | Geo. A. |
Young | Father's Surname |
| Father's Occupation | Butcher | American | Father's Nationality |
| Father's Birth Place | Winnego Co IL | 34 | Father's Age |
| Mother's Given Name | Melvina M. | Lansing | Mother's Maiden Name |
| Mother's Surname | Young | Boone Co IA | Mother's Residence |
| Mother's Nationality | American | Porter Co IN | Mother's Birth Place |
| Mother's Age | 30 | 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 | | |