| Certificate Number | 373 | | Date Issued |
| Child Given Name | |
Lough | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | F.B. |
Lough | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Ann E. | Hall | Mother's Maiden Name |
| Mother's Surname | Lough | | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 30 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |