| Certificate Number | 199 | | Date Issued |
| Child Given Name | |
Lapp | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Jul 1888 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Lapp | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 44 | Father's Age |
| Mother's Given Name | Amy | Alvard | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 41 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Rachael Marshall | Gilbert IA | Medical Attendant's Address |