| Certificate Number | 179 | | Date Issued |
| Child Given Name | |
Zook | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Aug 1885 |
Polk Co IA | Place of Birth |
| Father's Given Name | Henry |
Zook | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Margaret A. | Burus | Mother's Maiden Name |
| Mother's Surname | Zook | Polk Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |