| Certificate Number | 27 | | Date Issued |
| Child Given Name | Jay Carlos |
Glydden | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Aug 184 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John R.D. |
Glydden | Father's Surname |
| Father's Occupation | Grocery Clerk | American | Father's Nationality |
| Father's Birth Place | Marathon Broom Co NY | 23 | Father's Age |
| Mother's Given Name | Almeda | Day | Mother's Maiden Name |
| Mother's Surname | Glydden | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Oleney IL | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Louisa, Mrs. White | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | Louisa, Mrs. White | Ames IA | Certificate Signer's Address |
| Returned by Name | J.L., Mrs. Bartlett | | |