| Certificate Number | 235 | | Date Issued |
| Child Given Name | Guy |
Elzy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Apr 1890 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Elzy | Father's Surname |
| Father's Occupation | Drayman | | Father's Nationality |
| Father's Birth Place | Ohio | 34 | Father's Age |
| Mother's Given Name | Mary | Shockley | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 34 | 5 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |