| Certificate Number | 91 | | Date Issued |
| Child Given Name | Roy |
Crouthamel | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Feb 1888 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm. J. |
Crouthamel | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 48 | Father's Age |
| Mother's Given Name | Emma A. | Serff | Mother's Maiden Name |
| Mother's Surname | Crouthamel | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 33 | 4 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |