| Certificate Number | 365 | | Date Issued |
| Child Given Name | |
Heers | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 May 1886 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank W. |
Heers | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Des Moines Polk Co IA | 27 | Father's Age |
| Mother's Given Name | Jennie | Miller | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Missouri | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen M.D. | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen M.D. | Story City IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen M.D. | | |