| Certificate Number | 337 | | Date Issued |
| Child Given Name | Forrest Dean |
Cameron | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 May 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | W.A. |
Cameron | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Kentucky | 32 | Father's Age |
| Mother's Given Name | Elizabeth | Cramblitt | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 35 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |