| Certificate Number | 135 | | Date Issued |
| Child Given Name | |
Jones | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Apr 1890 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Elmer |
Jones | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | Stella | Harrison | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 15 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |