| Certificate Number | 122 | | Date Issued |
| Child Given Name | |
Bennetham | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Jun 1885 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Daniel |
Bennetham | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 30 | Father's Age |
| Mother's Given Name | Rebecca | Brown | Mother's Maiden Name |
| Mother's Surname | Bennethuam | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Frank Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Frank Thompson | | |