| Certificate Number | 323 | | Date Issued |
| Child Given Name | |
Bennethum | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Jun 1886 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | G.D. |
Bennethum | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 34 | Father's Age |
| Mother's Given Name | Sarah | Ray | Mother's Maiden Name |
| Mother's Surname | Bennethum | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 34 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F. Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | F. Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | F. Thompson | | |