| Certificate Number | 349 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 20 Feb 1882 |
Ontario Story Co IA | Place of Birth |
| Father's Given Name | George |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 40 | Father's Age |
| Mother's Given Name | Mary | Cameron | Mother's Maiden Name |
| Mother's Surname | Scott | Near Ontario Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | G.H. Merrideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.H. Merrideth | Ames IA | Certificate Signer's Address |
| Returned by Name | 'By mail' | | |