| Certificate Number | 401 | | Date Issued |
| Child Given Name | |
Gilmore | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Sep 1886 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm J> |
Gilmore | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 37 | Father's Age |
| Mother's Given Name | Jerusha | Martin | Mother's Maiden Name |
| Mother's Surname | Gilmore | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 30 | 9 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb | | |