| Certificate Number | 335 | | Date Issued |
| Child Given Name | |
Cory | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Jul 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | R.S. |
Cory | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 46 | Father's Age |
| Mother's Given Name | Melinda | Hackett | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 32 | 5 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |