| Certificate Number | 807 | | Date Issued |
| Child Given Name | |
Carmody | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Oct 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Carmody | Father's Surname |
| Father's Occupation | Carpenter | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 30 | Father's Age |
| Mother's Given Name | Sarah | Koin | Mother's Maiden Name |
| Mother's Surname | Carmody | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |