| Certificate Number | 800 | | Date Issued |
| Child Given Name | William Willis |
Adams | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Nov 1883 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Adams | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Chestire NY | 49 | Father's Age |
| Mother's Given Name | Julia A. | Cram | Mother's Maiden Name |
| Mother's Surname | Adams | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Chestire NY | Mother's Birth Place |
| Mother's Age | 42 | 8 | Number of Child This Mother |
| Medical Attendant's Name | H.S., Dr. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | H.S., Dr. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | H.S., Dr. Newton | | |