| Certificate Number | 363 | | Date Issued |
| Child Given Name | |
Ike | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Aug 1886 |
Boone Co IA | Place of Birth |
| Father's Given Name | G.B. |
Ike | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 33 | Father's Age |
| Mother's Given Name | Emma A. | Kelley | Mother's Maiden Name |
| Mother's Surname | Ike | Boone Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |