| Certificate Number | 17 | | Date Issued |
| Child Given Name | Maurice M. |
O'Maria | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Nov 1884 |
Polk Co IA | Place of Birth |
| Father's Given Name | Dennis |
O'Maria | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ireland | 45 | Father's Age |
| Mother's Given Name | Mary | Quirk | Mother's Maiden Name |
| Mother's Surname | O'Mara | Polk Co IA | Mother's Residence |
| Mother's Nationality | | Ireland | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.L. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L. Bartlett | | |