| Certificate Number | 1010 | | Date Issued |
| Child Given Name | |
Shadle | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Aug 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Howard F. |
Shadle | Father's Surname |
| Father's Occupation | Carpenter | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 29 | Father's Age |
| Mother's Given Name | Clara M. | Savitts | Mother's Maiden Name |
| Mother's Surname | Shadle | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |