| Certificate Number | 29 | | Date Issued |
| Child Given Name | |
Palmer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Nov 1887 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | F.M. |
Palmer | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Elena R. | Ruth | Mother's Maiden Name |
| Mother's Surname | Palmer | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |