| Certificate Number | 951 | | Date Issued |
| Child Given Name | |
Lounsbery | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Apr 1884 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | Jno |
Lounsberry | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 29 | Father's Age |
| Mother's Given Name | Roxie F. | Danskin | Mother's Maiden Name |
| Mother's Surname | Lounsbury | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 25 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |