| Certificate Number | 217 | | Date Issued |
| Child Given Name | |
Norris | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 22 Aug 1881 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Fred A. |
Norris | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 23 | Father's Age |
| Mother's Given Name | Aletha | French | Mother's Maiden Name |
| Mother's Surname | Norris | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Story Co IA | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno. I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno. I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno. I. Hostetter | | |