| Certificate Number | 227 | | Date Issued |
| Child Given Name | |
Roland | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Nov 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John |
Roland | Father's Surname |
| Father's Occupation | An Laborer | | Father's Nationality |
| Father's Birth Place | Holem Norway | 55 | Father's Age |
| Mother's Given Name | Julia | Anderson | Mother's Maiden Name |
| Mother's Surname | Roland | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Holem Norway | Mother's Birth Place |
| Mother's Age | 45 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | J.L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |