| Certificate Number | 216 | | Date Issued |
| Child Given Name | |
Mun | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 20 Aug 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Martin L. |
Mun | Father's Surname |
| Father's Occupation | Farmer & Teacher | American | Father's Nationality |
| Father's Birth Place | Ohio | 41 | Father's Age |
| Mother's Given Name | Nancy A. | Snively | Mother's Maiden Name |
| Mother's Surname | Mun | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 41 | 4 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |