| Certificate Number | 149 | | Date Issued |
| Child Given Name | |
Livingston | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Apr 1889 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | F.M. |
Livingston | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Iowa | 35 | Father's Age |
| Mother's Given Name | Bessie | Ringheim | Mother's Maiden Name |
| Mother's Surname | | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 35 | 2 | Number of Child This Mother |
| Medical Attendant's Name | W.H. Grafton | Cambridge IA | Medical Attendant's Address |