| Certificate Number | 29 | | Date Issued |
| Child Given Name | |
Brown | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 09 Jul 1880 |
Near Ames Story Co IA | Place of Birth |
| Father's Given Name | William |
Brown | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | | Gossard | Mother's Maiden Name |
| Mother's Surname | | Near Ames Story Co IA | Mother's Residence |
| Mother's Age | | 2 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merideth | Ames IA | Certificate Signer's Address |
| Returned by Name | 'By Mail' | | |