| Certificate Number | 582 | | Date Issued |
| Child Given Name | Jeremiah Emmet |
O'Mara | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Mar 1883 |
Polk Co IA | Place of Birth |
| Father's Given Name | Dennis |
O'Mara | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 41 | Father's Age |
| Mother's Given Name | Mary | Quirk | Mother's Maiden Name |
| Mother's Surname | O'Mara | Polk Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M Brown | | |