| Certificate Number | 912 | | Date Issued |
| Child Given Name | |
Jackson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Mar 1884 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Joseph |
Jackson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 34 | Father's Age |
| Mother's Given Name | Kate | Eply | Mother's Maiden Name |
| Mother's Surname | Jackson | Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 33 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Rachel Marshall | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | Rachel Marshall | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | Rachel Marshall | | |