| Certificate Number | 138 | | Date Issued |
| Child Given Name | |
Caufield | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Apr 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Chas C. |
Caufield | Father's Surname |
| Father's Occupation | Operator | | Father's Nationality |
| Father's Birth Place | Marshalltown Marshall Co IA | 22 | Father's Age |
| Mother's Given Name | Lillian | Garrett | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Cromwell Union Co IA | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |