| Certificate Number | 759 | | Date Issued |
| Child Given Name | |
Zenor | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Zenorville Story Co IA | Place of Birth |
| Father's Given Name | M. |
Zenor | Father's Surname |
| Father's Occupation | Teamster | American | Father's Nationality |
| Father's Birth Place | Iowa | 25 | Father's Age |
| Mother's Given Name | Mrs. | | Mother's Maiden Name |
| Mother's Surname | Zenor | Zenorville Story Co IA | Mother's Residence |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |