| Certificate Number | 279 | | Date Issued |
| Child Given Name | |
Chevalier | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Sep 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | W.F. |
Chevalier | Father's Surname |
| Father's Occupation | Teacher | | Father's Nationality |
| Father's Birth Place | Ohio | 29 | Father's Age |
| Mother's Given Name | Mary | Scott | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |