| Certificate Number | 333 | | Date Issued |
| Child Given Name | |
Hemstreet | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Feb 1882 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Albert N. |
Hemstreet | Father's Surname |
| Father's Occupation | Farmer | German | Father's Nationality |
| Father's Birth Place | Germany | 24 | Father's Age |
| Mother's Given Name | Delia S. | Thayer | Mother's Maiden Name |
| Mother's Surname | Hemstreet | | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton M.D. | | |