| Certificate Number | 31 | | Date Issued |
| Child Given Name | Ralph W. |
Lewis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Nov 1888 |
Lincoln Twp Polk Co IA | Place of Birth |
| Father's Given Name | Arthur W. |
Lewis | Father's Surname |
| Father's Occupation | Teacher | | Father's Nationality |
| Father's Birth Place | Marshall Co IA | 21 | Father's Age |
| Mother's Given Name | Helen M. | Richardson | Mother's Maiden Name |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |