| Certificate Number | 268 | | Date Issued |
| Child Given Name | |
Day | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Mar 1886 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | William S. |
Day | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 37 | Father's Age |
| Mother's Given Name | Nancy M. | | Mother's Maiden Name |
| Mother's Surname | Day | Sherman Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 6 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |