| Certificate Number | 34 | | Date Issued |
| Child Given Name | |
Cook | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Jul 1888 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Mike |
Cook | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 41 | Father's Age |
| Mother's Given Name | Rosana | Ellwood | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 39 | 7 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Jeffrey | Nevada IA | Medical Attendant's Address |