| Certificate Number | 61 | | Date Issued |
| Child Given Name | |
Chamberlain | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Oct 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Vanderlin |
Chamberlain | Father's Surname |
| Father's Occupation | Clerk | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 31 | Father's Age |
| Mother's Given Name | Julia | Cole | Mother's Maiden Name |
| Mother's Surname | Chamberlain | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Meridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Meridith | Ames IA | Certificate Signer's Address |
| Returned by Name | 'Mail' | | |