| Certificate Number | 636 | | Date Issued |
| Child Given Name | |
Pletcher | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Mar 1883 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Edwin |
Pletcher | Father's Surname |
| Father's Occupation | Laborer | German | Father's Nationality |
| Father's Birth Place | Ohio | 28 | Father's Age |
| Mother's Given Name | Sarah E. | Elliott | Mother's Maiden Name |
| Mother's Surname | Pletcher | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 5 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |