| Certificate Number | 709 | | Date Issued |
| Child Given Name | |
Minor | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Jul 1883 |
| Place of Birth |
| Father's Given Name | George |
Minor | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 27 | Father's Age |
| Mother's Given Name | May L. | | Mother's Maiden Name |
| Mother's Surname | Minor | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 6 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |