| Certificate Number | 176 | | Date Issued |
| Child Given Name | Marcellus Uriah |
Apple | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 19 May 1881 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Clark |
Apple | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | | 24 | Father's Age |
| Mother's Given Name | Corilla | Hyden | Mother's Maiden Name |
| Mother's Surname | Apple | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | 20 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.B. Richard | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | F.B. Richard | Nevada IA | Certificate Signer's Address |
| Returned by Name | F.B. Richard | | |