| Certificate Number | 334 | | Date Issued |
| Child Given Name | |
Bean | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 30 Jan 1882 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Syrus P. |
Bean | Father's Surname |
| Father's Occupation | Day Laborer & Drayman | American | Father's Nationality |
| Father's Birth Place | New York | 24 | Father's Age |
| Mother's Given Name | Omusanan? | Brown | Mother's Maiden Name |
| Mother's Surname | Bean | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton M.D. | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |