| Certificate Number | 244 | | Date Issued |
| Child Given Name | |
Clark | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Sep 1890 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas H. |
Clark | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 22 | Father's Age |
| Mother's Given Name | Alma | Bennett | Mother's Maiden Name |
| Mother's Surname | | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell Ia | Medical Attendant's Address |