| Certificate Number | 717 | | Date Issued |
| Child Given Name | Jesse Malone |
Wills | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Aug 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Charlie |
Wills | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 55 | Father's Age |
| Mother's Given Name | Melvina J. | Ball | Mother's Maiden Name |
| Mother's Surname | Wills | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |