| Certificate Number | 633 | | Date Issued |
| Child Given Name | |
Newton | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 May 1883 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | F.S. |
Newton | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | Vermont | 27 | Father's Age |
| Mother's Given Name | Carrie E. | Bardick | Mother's Maiden Name |
| Mother's Surname | Newton | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 20 | 1 | 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 | | |