| Certificate Number | 746 | | Date Issued |
| Child Given Name | George Fremont |
Kintsley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Sep 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John Francis |
Kintsley | Father's Surname |
| Father's Occupation | Barber | American | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Mary Jane | Haningan | Mother's Maiden Name |
| Mother's Surname | Kintsley | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.H., Mrs. Heighton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.H., Mrs. Heighton | Ames IA | Certificate Signer's Address |
| Returned by Name | J.S., Mrs. Bartlett | | |