| Certificate Number | 22 | | Date Issued |
| Child Given Name | Earnest |
Warren | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Oct 1884 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Jefferson C. |
Warren | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 33 | Father's Age |
| Mother's Given Name | Mary R. | Huff | Mother's Maiden Name |
| Mother's Surname | Warren | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 34 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |