| Certificate Number | 283 | | Date Issued |
| Child Given Name | John E. Jr. |
Stevens | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Dec 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John L. |
Stevens | Father's Surname |
| Father's Occupation | Judge | | Father's Nationality |
| Father's Birth Place | Vermont | 37 | Father's Age |
| Mother's Given Name | Rowena | Edson | Mother's Maiden Name |
| Mother's Surname | Stevens | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |