| Certificate Number | 36 | | Date Issued |
| Child Given Name | Clyde |
McCoy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Nov 1889 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Fred |
McCoy | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Green Co IA | 23 | Father's Age |
| Mother's Given Name | Amanda | Eckard | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |