| Certificate Number | 300 | | Date Issued |
| Child Given Name | |
Robison | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 15 Jan 1882 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Joseph P. |
Robinson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Scott Co IA | 45 | Father's Age |
| Mother's Given Name | Mary E. | Tichenor | Mother's Maiden Name |
| Mother's Surname | Robinson | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 44 | 9 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler M.D. | | |