| Certificate Number | 200 | | Date Issued |
| Child Given Name | |
Herrs | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 24 Aug 1890 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank W. |
Herrs | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 31 | 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 | 31 | 4 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |