| Certificate Number | 28 | | Date Issued |
| Child Given Name | Milton Worth |
Delhorbe | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Nov 1884 |
I.A.C. Farm Ames IA | Place of Birth |
| Father's Given Name | Eli Augustus |
Delhorbe | Father's Surname |
| Father's Occupation | Foreman Farm | French | Father's Nationality |
| Father's Birth Place | East of Paris France | 38 | Father's Age |
| Mother's Given Name | Martha Josephine | Worth | Mother's Maiden Name |
| Mother's Surname | Delhorbe | I.A.C. Farm | Mother's Residence |
| Mother's Nationality | American | Newton OH | Mother's Birth Place |
| Mother's Age | 32 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Baughman, Nurse | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | Mrs. Baughman, Nurse | Ontario IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |