| Certificate Number | 208 | | Date Issued |
| Child Given Name | Earl Maxwell |
Rice | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 09 Jul 1881 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | E. Carter |
Rice | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Hattie May | Maxwell | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 20 | 1 | 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 | G.A. Merideth | | |