| Certificate Number | 78 | | Date Issued |
| Child Given Name | Clarence Jerome |
Burdick | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Nov 1884 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | F.D. |
Burdick | Father's Surname |
| Father's Occupation | Music Dealer | | Father's Nationality |
| Father's Birth Place | Illinois | 45 | Father's Age |
| Mother's Given Name | S.E. | Balliett | Mother's Maiden Name |
| Mother's Surname | Burdick | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Fanny McLain | Warren Twp | Medical Attendant's Address |
| Certificate Signer's Name | Fanny McLain | Warren Twp | Certificate Signer's Address |
| Returned by Name | Fanny McLain | | |