| Certificate Number | 133 | | Date Issued |
| Child Given Name | Theron Edward |
Adams | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Apr 1890 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | E.W. |
Adams | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 23 | Father's Age |
| Mother's Given Name | Mary | Wickham | Mother's Maiden Name |
| Mother's Surname | | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |