| Certificate Number | 848 | | Date Issued |
| Child Given Name | Bessie |
Beckley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Nov 1883 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | John W. |
Beckley | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 28 | Father's Age |
| Mother's Given Name | Francis | Crouse | Mother's Maiden Name |
| Mother's Surname | Beckley | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Beckley & Southwick | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |