| Certificate Number | 506 | | Date Issued |
| Child Given Name | |
Neet | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 25 Nov 1882 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Arch |
Neal | Father's Surname |
| Father's Occupation | Section Boss | American | Father's Nationality |
| Father's Birth Place | Kentucky | 33 | Father's Age |
| Mother's Given Name | America | Tegwood | Mother's Maiden Name |
| Mother's Surname | Neal | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 4 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |