| Certificate Number | 196 | | Date Issued |
| Child Given Name | |
Kirk | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Jun 1889 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Jas. H. |
Kirk | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Kentucky | 56 | Father's Age |
| Mother's Given Name | Elizabeth C. | Warren | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 44 | 10 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |