| Certificate Number | 162 | | Date Issued |
| Child Given Name | Clifford Elsworth |
Shockley | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 10 May 1881 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Jacob A. |
Shockley | Father's Surname |
| Father's Occupation | R R Employ | American | Father's Nationality |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Rachel Julette | Baldwin | Mother's Maiden Name |
| Mother's Surname | Shockley | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 29 | 8 | Number of Child This Mother |
| Medical Attendant's Name | S.J. Starr | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | S.J. Starr | Ames IA | Certificate Signer's Address |
| Returned by Name | 'mail' | | |