| Certificate Number | 170 | | Date Issued |
| Child Given Name | Harry G. |
Benethum | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 09 May 1881 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo D. |
Benethum | Father's Surname |
| Father's Occupation | Farmer of Iowa Center | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 29 | Father's Age |
| Mother's Given Name | Mariah | Smith | Mother's Maiden Name |
| Mother's Surname | Benethum | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E. Bowen | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | E. Bowen | Cambridge IA | Certificate Signer's Address |
| Returned by Name | E. Bowen | | |