| Certificate Number | 676 | | Date Issued |
| Child Given Name | |
May | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 May 1883 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | J.A. |
May | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 48 | Father's Age |
| Mother's Given Name | Luanna | Stratton | Mother's Maiden Name |
| Mother's Surname | Maynard | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 42 | 10 | 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 | | |