| Certificate Number | 203 | | Date Issued |
| Child Given Name | |
Yocum | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Irwin |
Yocum | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 30 | Father's Age |
| Mother's Given Name | Elmira | Miller | Mother's Maiden Name |
| Mother's Surname | Yocum | Union Twp Story Co IA | Mother's Residence |
| Mother's Age | 28 | 5 | 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 | | |