| Certificate Number | 565 | | Date Issued |
| Child Given Name | Charles F. |
Reed | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Jan 1883 |
Illinois Grove IA | Place of Birth |
| Father's Given Name | Edgar D. |
Reed | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 30 | Father's Age |
| Mother's Given Name | Harriet | Holcomb | Mother's Maiden Name |
| Mother's Surname | Reed | Illinois Grove IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Bell Thayers | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | Bill Thayers | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.M. Brooks | | |