| Certificate Number | 422 | | Date Issued |
| Child Given Name | |
Jurouex | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Jul 1886 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Julius |
Jerouex | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Canada | 40 | Father's Age |
| Mother's Given Name | Mary | Dewars | Mother's Maiden Name |
| Mother's Surname | Jurouex | | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |