| Certificate Number | 23 | | Date Issued |
| Child Given Name | |
Bates | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Oct 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | C. |
Bates | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Michigan | 27 | Father's Age |
| Mother's Given Name | Sophie | Olson | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Denmark | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |