| Certificate Number | 106 | | Date Issued |
| Child Given Name | |
Baldis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Apr 1883 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | William |
Baldis | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 30 | Father's Age |
| Mother's Given Name | Bertha | Goos | Mother's Maiden Name |
| Mother's Surname | Baldis | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B. Fallen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B. Fallen | Story City IA | Certificate Signer's Address |
| Returned by Name | B. Fallen | | |