| Certificate Number | 1005 | | Date Issued |
| Child Given Name | C. Edward |
Paterson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Jul 1884 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | G.Y. |
Paterson | Father's Surname |
| Father's Occupation | Agt. | American | Father's Nationality |
| Father's Birth Place | New York | 23 | Father's Age |
| Mother's Given Name | Sarah J. | Cox | Mother's Maiden Name |
| Mother's Surname | Paterson | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |