| Certificate Number | 115 | | Date Issued |
| Child Given Name | |
Hutchison | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Feb 1889 |
Kelley Story Co IA | Place of Birth |
| Father's Given Name | James |
Hutchison | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ireland | 33 | Father's Age |
| Mother's Given Name | Mary E. | Mills | Mother's Maiden Name |
| Mother's Surname | | Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 31 | 4 | Number of Child This Mother |
| Medical Attendant's Name | B.D. Miller | Kelley IA | Medical Attendant's Address |