| Child Given Name | Jeane Leo |
Edgar | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 30 Apr 1887 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Asbury Porter |
Edgar | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | | 36 | Father's Age |
| Mother's Given Name | Mary Allura | Thompson | Mother's Maiden Name |
| Mother's Surname | | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Ames Story Co IA | Mother's Birth Place |
| Mother's Age | 32 | | Number of Child This Mother |
| Medical Attendant's Name | J.I., Dr. Hostetter | | Medical Attendant's Address |
| Certificate Signer's Name | Rose Hand | | Certificate Signer's Address |