| Certificate Number | 220 | | Date Issued |
| Child Given Name | |
Hill | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Jul 1889 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Oliver |
Hill | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Norway | 40 | Father's Age |
| Mother's Given Name | Clara | Seymour | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Norway | Mother's Birth Place |
| Mother's Age | 39 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |