| Certificate Number | 750 | | Date Issued |
| Child Given Name | Floyd |
McHone | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Jun 1883 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Augustus |
McHone | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 20 | Father's Age |
| Mother's Given Name | Hannah | Eastwood | Mother's Maiden Name |
| Mother's Surname | McHone | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Nebraska | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Frank Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Frank Thompson | | |