| Certificate Number | 683 | | Date Issued |
| Child Given Name | |
Dally | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Hamilton Co IA | Place of Birth |
| Father's Given Name | R.B. |
Dally | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 25 | Father's Age |
| Mother's Given Name | Martha A. | Farington | Mother's Maiden Name |
| Mother's Surname | Dally | Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Abby M. Penn | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Abbey M. Penn | Nevada IA | Certificate Signer's Address |
| Returned by Name | Abby M. Penn | | |