| Certificate Number | 914 | | Date Issued |
| Child Given Name | Fred Albert |
Clark | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Feb 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Joseph B. |
Clark | Father's Surname |
| Father's Occupation | Teamster | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 36 | Father's Age |
| Mother's Given Name | Irene | Cooley | Mother's Maiden Name |
| Mother's Surname | Clark | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 33 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.S. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.S. Bartlett | | |