| Certificate Number | 269 | | Date Issued |
| Child Given Name | Clarence J. |
Hennick | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Apr 1886 |
| Place of Birth |
| Father's Given Name | John |
Hennick | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | M.E. | Olinger | Mother's Maiden Name |
| Mother's Surname | Hennick | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | John Hennick | Cambridge IA | Medical Attendant's Address |