| Certificate Number | 364 | | Date Issued |
| Child Given Name | |
Hess | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 28 Mar 1882 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Robert A. |
Hess | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 28 | Father's Age |
| Mother's Given Name | Ruth Ann | Thomas | Mother's Maiden Name |
| Mother's Surname | Hess | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |