| Certificate Number | 1008 | | Date Issued |
| Child Given Name | Otis Floyd |
Dragoo | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Mar 1884 |
Kelley Story Co IA | Place of Birth |
| Father's Given Name | James P. |
Dragoo | Father's Surname |
| Father's Occupation | Grainery Business | | Father's Nationality |
| Mother's Given Name | Margaret Ann | Neward | Mother's Maiden Name |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |