| Certificate Number | 474 | | Date Issued |
| Child Given Name | |
Kent | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Dec 1886 |
Story Co IA | Place of Birth |
| Father's Given Name | John |
Kent | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 51 | Father's Age |
| Mother's Given Name | Elizabeth | Terry | Mother's Maiden Name |
| Mother's Surname | Kent | Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 49 | 5 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |