| Certificate Number | 179 | | Date Issued |
| Child Given Name | |
Oliver | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 May 1889 |
Huxley Story Co IA | Place of Birth |
| Father's Given Name | J.W. |
Oliver | Father's Surname |
| Father's Occupation | R.R. Agt. | | Father's Nationality |
| Father's Birth Place | Indiana | 24 | Father's Age |
| Mother's Given Name | Hattie H. | Evans | Mother's Maiden Name |
| Mother's Surname | | Huxley Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |