| Certificate Number | 692 | | Date Issued |
| Child Given Name | Arthur Elsworth |
Ham | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 May 1883 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Theodore |
Ham | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | Josephine | Ware | Mother's Maiden Name |
| Mother's Surname | Ham | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | | 6 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |