| Certificate Number | 557 | | Date Issued |
| Child Given Name | |
Shepard | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | E. |
Shepard | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 32 | Father's Age |
| Mother's Given Name | Emma | Sarger | Mother's Maiden Name |
| Mother's Surname | Shepard | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |