| Certificate Number | 430 | | Date Issued |
| Child Given Name | |
McConnell | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Sep 1886 |
| Place of Birth |
| Father's Given Name | Alex |
McConnell | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 57 | Father's Age |
| Mother's Given Name | Charlotte Ann | Fenton | Mother's Maiden Name |
| Mother's Surname | McConnell | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 29 | 2 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |