| Certificate Number | 828 | | Date Issued |
| Child Given Name | Tracy Austin |
Nae | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Dec 1883 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | J. Mariam |
Nae | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 26 | Father's Age |
| Mother's Given Name | Sarah L. | Black | Mother's Maiden Name |
| Mother's Surname | Nae | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J.I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | J.I. Hostetter | | |