| Certificate Number | 4 | | Date Issued |
| Child Given Name | |
Bacon | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Aug 1891 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | R.O. |
Bacon | Father's Surname |
| Father's Occupation | Printer | | Father's Nationality |
| Father's Birth Place | Vermont | 23 | Father's Age |
| Mother's Given Name | Bertha E. | Dulin | Mother's Maiden Name |
| Mother's Surname | Bacon | | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A. Richmond | Ames IA | Medical Attendant's Address |
| Returned by Name | A. Richmond | | |