| Certificate Number | 294 | | Date Issued |
| Child Given Name | Daniel |
Hurst | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Apr 1886 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Amos |
Hurst | Father's Surname |
| Father's Birth Place | Pennsylvania | 46 | Father's Age |
| Mother's Given Name | Mary | Conrad | Mother's Maiden Name |
| Mother's Surname | Hurst | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 43 | 9 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |