| Certificate Number | 1003 | | Date Issued |
| Child Given Name | |
McConnell | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Jul 1884 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Alexander |
McConnell | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 55 | Father's Age |
| Mother's Given Name | Charlotte Ann | Fenton | Mother's Maiden Name |
| Mother's Surname | McConnell | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Vanderwalker | Peoria IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Vanderwalker | Peoria IA | Certificate Signer's Address |
| Returned by Name | J.W. Vanderwalker | | |