| Certificate Number | 3 | | Date Issued |
| Child Given Name | |
McCarthy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Oct 1891 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Arr |
McCarthy | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 20 | Father's Age |
| Mother's Given Name | Lida M. | Palmatier | Mother's Maiden Name |
| Mother's Surname | McCarthy | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A. Richmond | Ames IA | Medical Attendant's Address |