| Certificate Number | 452 | | Date Issued |
| Child Given Name | |
Pointer | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Sep 1882 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Daniel |
Pointer | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Ohio | 43 | Father's Age |
| Mother's Given Name | Emma W. | Belcher | Mother's Maiden Name |
| Mother's Surname | Pointer | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | B.O., Mrs. Higley | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | B.O., Mrs. Higley | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | B.O., Mrs. Higley | | |