| Certificate Number | 836 | | Date Issued |
| Child Given Name | |
Rex | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Dec 1883 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Rex | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Jefferson Co OH | 23 | Father's Age |
| Mother's Given Name | Lulu | Winters | Mother's Maiden Name |
| Mother's Surname | Rex | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Jefferson Co OH | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |