| Certificate Number | 194 | | Date Issued |
| Child Given Name | Carroll George |
Underwood | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Nov 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Geo. A. |
Underwood | Father's Surname |
| Father's Occupation | Lawyer | | Father's Nationality |
| Father's Birth Place | Illinois | 34 | Father's Age |
| Mother's Given Name | Augusta | Ames | Mother's Maiden Name |
| Mother's Surname | Underwood | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |