| Certificate Number | 21 | | Date Issued |
| Child Given Name | Willie Lien |
Reasoner | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Nov 1884 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | W.G. |
Reasoner | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 25 | Father's Age |
| Mother's Given Name | Carrie | Hounicker | Mother's Maiden Name |
| Mother's Surname | Reasoner | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New Jersey | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |