| Certificate Number | 210 | | Date Issued |
| Child Given Name | |
Anderson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jul 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm S. |
Anderson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 46 | Father's Age |
| Mother's Given Name | Melvina | Jelliott | Mother's Maiden Name |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 38 | 6 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |