| Certificate Number | 526 | | Date Issued |
| Child Given Name | |
Jones | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Nov 1882 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | J.M. |
Jones | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 29 | Father's Age |
| Mother's Given Name | Lucinda | Marsh | Mother's Maiden Name |
| Mother's Surname | Jones | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | L.W. Howes | Elsworth IA | Medical Attendant's Address |
| Certificate Signer's Name | L.W. Howes | Elsworth IA | Certificate Signer's Address |
| Returned by Name | L.W. Howes | | |