| Certificate Number | 10 | | Date Issued |
| Child Given Name | |
Breezley | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Sep 1884 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | William J. |
Breezley | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Palestine | 21 | Father's Age |
| Mother's Given Name | Mary Roselea | Hanks | Mother's Maiden Name |
| Mother's Surname | Breezley | ? County | Mother's Residence |
| Mother's Nationality | | Union Twp Story Co IA | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hays | | |