| Certificate Number | 826 | | Date Issued |
| Child Given Name | Jean Q. |
Breezley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Nov 1883 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | John D. |
Breezley | Father's Surname |
| Father's Occupation | Retired Merchant | American | Father's Nationality |
| Father's Birth Place | Vermillion Co IL | 49 | Father's Age |
| Mother's Given Name | Rebbecca Ellen | Amspiger | Mother's Maiden Name |
| Mother's Surname | Breezley | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Vermillion Co IL | Mother's Birth Place |
| Mother's Age | 39 | 9 | Number of Child This Mother |
| Medical Attendant's Name | Wm H. Grafton | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | Wm H. Grafton | Cambridge IA | Certificate Signer's Address |
| Returned by Name | Wm H. Grafton | | |