| Certificate Number | 42 | | Date Issued |
| Child Given Name | |
Shelton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Nov 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Josiah |
Shelton | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 32 | Father's Age |
| Mother's Given Name | Relda A. | Jackson | Mother's Maiden Name |
| Mother's Surname | Shelton | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |