| Certificate Number | 203 | | Date Issued |
| Child Given Name | Hillis Henry |
Crain | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 May 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Arthur L. |
Crain | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New Hampshire | 30 | Father's Age |
| Mother's Given Name | Caroline E. | Bailey | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Missouri | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |