| Certificate Number | 315 | | Date Issued |
| Child Given Name | Freddie |
Hackett | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Jul 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Fred |
Hackett | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | | 24 | Father's Age |
| Mother's Given Name | Minnie | Hannum | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Ames Story Co IA | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |