| Certificate Number | 694 | | Date Issued |
| Child Given Name | |
Hemstreet | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Jan 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Marshall |
Hemstreet | Father's Surname |
| Father's Occupation | Ins. Agent | American | Father's Nationality |
| Father's Birth Place | New York | 42 | Father's Age |
| Mother's Given Name | Pluma A. | Williams | Mother's Maiden Name |
| Mother's Surname | Hemstreet | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 41 | 8 | 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 | | |