| Certificate Number | 612 | | Date Issued |
| Child Given Name | |
Proaty | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Apr 1883 |
| Place of Birth |
| Father's Given Name | Milton |
Proaty | Father's Surname |
| Mother's Given Name | Maggie | Fry | Mother's Maiden Name |
| Mother's Surname | | Iowa Center Story Co IA | Mother's Residence |
| Mother's Age | | 5 | 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 | | |