| Certificate Number | 106 | | Date Issued |
| Child Given Name | |
Allen | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Mar 1890 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Allen | Father's Surname |
| Father's Occupation | Blacksmith | | Father's Nationality |
| Father's Birth Place | Scotland | 44 | Father's Age |
| Mother's Given Name | Mary | McCracken | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Scotland | Mother's Birth Place |
| Mother's Age | 38 | ? | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |