| Certificate Number | 63 | | Date Issued |
| Child Given Name | |
Patterson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Oct 1880 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Elza |
Patterson | Father's Surname |
| Father's Occupation | Groceryman | American | Father's Nationality |
| Father's Birth Place | Ohio | 30 | Father's Age |
| Mother's Given Name | Marcella Jane | | Mother's Maiden Name |
| Mother's Surname | Patterson | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 25 | 4 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merideth | Ames IA | Certificate Signer's Address |
| Returned by Name | 'mail' | | |