| Certificate Number | 34 | | Date Issued |
| Child Given Name | |
Foster | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Dec 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Clay |
Foster | Father's Surname |
| Father's Birth Place | Story Co IA | | Father's Age |
| Mother's Given Name | Emma | Cloud | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 20 | 1 | 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 | | |