| Certificate Number | 125 | | Date Issued |
| Child Given Name | Mark Jr. |
Fortune | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Sep 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Mark |
Fortune | Father's Surname |
| Father's Occupation | Comcl Traveler | | Father's Nationality |
| Father's Birth Place | Virginia | 43 | Father's Age |
| Mother's Given Name | Ada | Parsons | Mother's Maiden Name |
| Mother's Surname | Fortune | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 30 | 3 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |