| Certificate Number | 641 | | Date Issued |
| Child Given Name | |
Cook | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 May 1883 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | John W. |
Cook | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 39 | Father's Age |
| Mother's Given Name | Rebecca E. | Jackson | Mother's Maiden Name |
| Mother's Surname | Cook | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 38 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |