| Certificate Number | 456 | | Date Issued |
| Child Given Name | |
Ham | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Sep 1882 |
Kelley Story Co IA | Place of Birth |
| Father's Given Name | Jeremiah |
Ham | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | 39 | Father's Age |
| Mother's Given Name | Mary A. | Carney | Mother's Maiden Name |
| Mother's Surname | Ham | Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 37 | 7 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton M.D. | | |