| Certificate Number | 267 | | Date Issued |
| Child Given Name | |
Ruby | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 18 Nov 1881 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Milus W. |
| Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 22 | Father's Age |
| Mother's Given Name | Edith L. | Gaston | Mother's Maiden Name |
| Mother's Surname | Ruby | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P.H. Sharp | Kelley IA | Medical Attendant's Address |
| Certificate Signer's Name | P.H. Sharp | Kelley IA | Certificate Signer's Address |
| Returned by Name | P.H. Sharp | | |