| Certificate Number | 191 | | Date Issued |
| Child Given Name | |
Carpenter | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Feb 1887 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Jas. T. |
Carpenter | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Massachusets | 42 | Father's Age |
| Mother's Given Name | Fannie J. | Tillotson | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Michigan | Mother's Birth Place |
| Mother's Age | 30 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Abby M. Penn | Nevada IA | Medical Attendant's Address |