| Certificate Number | 100 | | Date Issued |
| Child Given Name | |
Joor | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Jan 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Peter |
Joor | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Nevada Story Co IA | 32 | Father's Age |
| Mother's Given Name | Esther | Brodie | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Scotland | Mother's Birth Place |
| Mother's Age | 32 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell IA | Medical Attendant's Address |