| Certificate Number | 243 | | Date Issued |
| Child Given Name | Anson |
Charlton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Sep 1888 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | L.A. |
Charlton | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Canada | 29 | Father's Age |
| Mother's Given Name | Maggie | Matheny | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |