| Certificate Number | 677 | | Date Issued |
| Child Given Name | Charles |
Irvin | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jun 1883 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Johnston |
Irvin | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 25 | Father's Age |
| Mother's Given Name | Tina | Menzell | Mother's Maiden Name |
| Mother's Surname | Irvin | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | German | Germany | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Fanny McLane | Warren Twp IA | Medical Attendant's Address |
| Certificate Signer's Name | Fanny McLane | Warren Twp IA | Certificate Signer's Address |
| Returned by Name | Fanny McLane | | |