| Certificate Number | 4 | | Date Issued |
| Child Given Name | Vern |
Proctor | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Sep 1884 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
Proctor | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Canada | 29 | Father's Age |
| Mother's Given Name | C.M. | Hoskins | Mother's Maiden Name |
| Mother's Surname | Procter | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |