| Certificate Number | 261 | | Date Issued |
| Child Given Name | |
Beck | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Mar 1886 |
| Place of Birth |
| Father's Given Name | D.W.C. |
Beck | Father's Surname |
| Father's Occupation | V.S. and Druggist | | Father's Nationality |
| Father's Birth Place | Illinois | 45 | Father's Age |
| Mother's Given Name | Barbara | Maloy | Mother's Maiden Name |
| Mother's Surname | Beck | Cambridge Story Co IA | Mother's Residence |
| Mother's Age | 30 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown M.D. | Cambridge IA | Medical Attendant's Address |