| Child Given Name | Jasper Clinton |
Bates | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 03 Jul 1888 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Theron Landon |
Bates | Father's Surname |
| Father's Occupation | Farming | | Father's Nationality |
| Father's Birth Place | Michigan | 29 | Father's Age |
| Mother's Given Name | Arminda | Womack | Mother's Maiden Name |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Aplin | | Medical Attendant's Address |
| Certificate Signer's Name | Theron, Mrs. Bates | Cambridge IA | Certificate Signer's Address |