| Certificate Number | 749 | | Date Issued |
| Child Given Name | |
Gamble | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Sep 1883 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Gamble | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Claire | Maxwell | Mother's Maiden Name |
| Mother's Surname | Gamble | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana? | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.O., Mrs. Kegly | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | B.O., Mrs. Kegly | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | B.O., Mrs. Kegly | | |