| Certificate Number | 351 | | Date Issued |
| Child Given Name | |
May | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 08 Mar 1882 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
May | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 20 | Father's Age |
| Mother's Given Name | Dorothy L. | Hopkins | Mother's Maiden Name |
| Mother's Surname | Maynard | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | 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 | | |