| Certificate Number | 269 | | Date Issued |
| Child Given Name | |
Link | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Aug 1889 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Link | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Germany | 41 | Father's Age |
| Mother's Given Name | May L. | Webber | Mother's Maiden Name |
| Mother's Surname | | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Germany | Mother's Birth Place |
| Mother's Age | 37 | 7 | Number of Child This Mother |
| Medical Attendant's Name | A.S. Aplin | Cambridge IA | Medical Attendant's Address |