| Certificate Number | 5 | | Date Issued |
| Child Given Name | Milvin |
Bunce | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Sep 1884 |
Gilbert Station Story Co IA | Place of Birth |
| Father's Given Name | D.K. |
Bunce | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Kane Co IL | 40 | Father's Age |
| Mother's Given Name | Lizzie | Linirode | Mother's Maiden Name |
| Mother's Surname | Bunce | Gilbert Station Story Co IA | Mother's Residence |
| Mother's Nationality | | Whiteside Co IL | Mother's Birth Place |
| Mother's Age | 36 | 6 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |