| Certificate Number | 481 | | Date Issued |
| Child Given Name | |
Vanscoy | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Feb 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | James |
Vanscoy | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 29 | Father's Age |
| Mother's Given Name | Matilda | Sherman | Mother's Maiden Name |
| Mother's Surname | Vanscoy | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 5 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |