| Certificate Number | 222 | | Date Issued |
| Child Given Name | Guyland F. |
Balliet | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Jul 1882 |
| Place of Birth |
| Father's Given Name | J.M. |
Balliet | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 41 | Father's Age |
| Mother's Given Name | Emma | Hutchinson | Mother's Maiden Name |
| Mother's Surname | Balliet | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 36 | 4 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |