| Certificate Number | 809 | | Date Issued |
| Child Given Name | |
Adams | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Nov 1883 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | J.C. |
Adams | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 30 | Father's Age |
| Mother's Given Name | Litta | Andrews | Mother's Maiden Name |
| Mother's Surname | Adams | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |