| Certificate Number | 114 | | Date Issued |
| Child Given Name | |
Yazel | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 31 Dec 1880 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | David P. |
Yazel | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 39 | Father's Age |
| Mother's Given Name | Lucinda | Kidmore | Mother's Maiden Name |
| Mother's Surname | Yazel | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 32 | | 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 | | |