| Certificate Number | 193 | | Date Issued |
| Child Given Name | |
Adams | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 38 May 1889 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Walter J. |
Adams | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Canada | 36 | Father's Age |
| Mother's Given Name | Emma | McLean | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 35 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |