| Certificate Number | 99 | | Date Issued |
| Child Given Name | |
Bales | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Jan 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | David D. |
Bales | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | Story Co IA | 26 | Father's Age |
| Mother's Given Name | Mary | Carpenter | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |