| Certificate Number | 207 | | Date Issued |
| Child Given Name | |
Maxwell | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Aug 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | C. |
Maxwell | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Wisconson | 22 | Father's Age |
| Mother's Given Name | Minnie | Erb | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |