| Certificate Number | 44 | | Date Issued |
| Child Given Name | Eugene Henry |
Person | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Sep 1880 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Clarence |
Person | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Massachusets | 29 | Father's Age |
| Mother's Given Name | Ellen | Newkirk | Mother's Maiden Name |
| Mother's Surname | Person | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merideth | Ames IA | Certificate Signer's Address |
| Returned by Name | 'mail' | | |