| Certificate Number | 490 | | Date Issued |
| Child Given Name | James William H. |
Brown | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Oct 1882 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | James |
Brown | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 22 | Father's Age |
| Mother's Given Name | Susanna | Taylor | Mother's Maiden Name |
| Mother's Surname | Brown | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |