| Certificate Number | 569 | | Date Issued |
| Child Given Name | |
Cook | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Jan 183 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | A. Gaston |
Cook | Father's Surname |
| Father's Occupation | Photographer | American | Father's Nationality |
| Father's Birth Place | Illinois | 37 | Father's Age |
| Mother's Given Name | Abia Hale | Shields | Mother's Maiden Name |
| Mother's Surname | Cook | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 34 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Jane, Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | Jane, Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | Jane, Mrs. Bartlett | | |