| Certificate Number | 622 | | Date Issued |
| Child Given Name | |
Price | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 14 Sep 1887 |
| Place of Birth |
| Father's Given Name | Leroy |
Price | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Marshall Co IA | 28 | Father's Age |
| Mother's Given Name | Ruth E. | Miller | Mother's Maiden Name |
| Mother's Surname | Price | Hardin Co IA | Mother's Residence |
| Mother's Nationality | | Marshall Co IA | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |