| Certificate Number | 146 | | Date Issued |
| Child Given Name | |
Reading | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 29 Mar 1881 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Lewis |
Reading | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 22 | Father's Age |
| Mother's Given Name | Mary | Shinkle | Mother's Maiden Name |
| Mother's Surname | Reading | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | L.W. Thomas | Edenville IA | Medical Attendant's Address |
| Certificate Signer's Name | L.W. Thomas | Edenville IA | Certificate Signer's Address |
| Returned by Name | L.W. Thomas | | |