| Certificate Number | 128 | | Date Issued |
| Child Given Name | Robert Patrick |
Burus | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Nov 1884 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Patrick |
Burus | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Mother's Given Name | Melissa A. | Elliott | Mother's Maiden Name |
| Mother's Surname | Burus | Grant Twp Story Co IA | Mother's Residence |
| Mother's Age | | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |