| Certificate Number | 995 | | Date Issued |
| Child Given Name | |
Allen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Jul 1884 |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | Charles W. |
Allen | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | Vermont | 28 | Father's Age |
| Mother's Given Name | Angie S. | Stewart | Mother's Maiden Name |
| Mother's Surname | Allen | Gilbert Story Co IA | Mother's Residence |
| Mother's Nationality | American | Vermont | Mother's Birth Place |
| Mother's Age | 30 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Gilbert IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Gilbert IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |