| Certificate Number | 36 | | Date Issued |
| Child Given Name | |
Pace | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Oct 1888 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Nathan |
Pace | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Perry Co OH | 38 | Father's Age |
| Mother's Given Name | Esther | Lyons | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Perry Co OH | Mother's Birth Place |
| Mother's Age | 37 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell IA | Medical Attendant's Address |