| Certificate Number | 99 | | Date Issued |
| Child Given Name | |
May | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 29 Dec 1880 |
Ballard Grove Story Co IA | Place of Birth |
| Father's Given Name | John |
May | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Hewey Co IN | 45 | Father's Age |
| Mother's Given Name | Lurana H. | Statton | Mother's Maiden Name |
| Mother's Surname | Maynard | Ballard Grove Story Co IA | Mother's Residence |
| Mother's Nationality | American | Henry Co IN | Mother's Birth Place |
| Mother's Age | | 9 | 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 | | |