| Certificate Number | 13 | | Date Issued |
| Child Given Name | |
Homes | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Sep 1887 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas. M. |
Homes | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 30 | Father's Age |
| Mother's Given Name | Hellen | Adams | Mother's Maiden Name |
| Mother's Surname | Homes | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |