| Certificate Number | 439 | | Date Issued |
| Child Given Name | Vally Leroy |
Foster | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Nov 1886 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Albert |
Foster | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 28 | Father's Age |
| Mother's Given Name | Lucy | Smith | Mother's Maiden Name |
| Mother's Surname | Foster | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 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 | | |