| Certificate Number | 521 | | Date Issued |
| Child Given Name | |
Conway | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Nov 1882 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Alfred W. |
Conway | Father's Surname |
| Father's Occupation | Clerk | American | Father's Nationality |
| Father's Birth Place | Indiana | 23 | Father's Age |
| Mother's Given Name | Fannie | Rucker | Mother's Maiden Name |
| Mother's Surname | Conway | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Missouri | Mother's Birth Place |
| Mother's Age | 20 | 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 | G.A. Meridith | | |