| Certificate Number | 453 | | Date Issued |
| Child Given Name | |
Kaness | Child Surname |
| Child Sex | 5 |
W | Child Race |
| Date of Birth | 15 Oct 1886 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
Kaness | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 42 | Father's Age |
| Mother's Given Name | Mary Amelia | Bates | Mother's Maiden Name |
| Mother's Surname | Kaness | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 35 | | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |