| Certificate Number | 207 | | Date Issued |
| Child Given Name | |
Hall | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Dec 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | |
Hall | Father's Surname |
| Father's Occupation | Cooper | | Father's Nationality |
| Father's Birth Place | Norway | 25 | Father's Age |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |