| Certificate Number | 399 | | Date Issued |
| Child Given Name | Agnes Adelaide |
Young | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Oct 1886 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Alonzo |
Young | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 31 | Father's Age |
| Mother's Given Name | Barbara A. | Gregory | Mother's Maiden Name |
| Mother's Surname | Young | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 5 | 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 | | |