| Certificate Number | 490 | | Date Issued |
| Child Given Name | |
Day | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 16 Jun 1882 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | William |
Day | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | 31 | Father's Age |
| Mother's Given Name | Mary Ann | Kluie | Mother's Maiden Name |
| Mother's Surname | Day | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 4 | Number of Child This Mother |
| Medical Attendant's Name | L.H. Bennett M.D. | Clyde IA | Medical Attendant's Address |
| Certificate Signer's Name | L.H. Bennett M.D. | Clyde IA | Certificate Signer's Address |
| Returned by Name | L.H. Bennett M.D. | | |