| Certificate Number | 203 | | Date Issued |
| Child Given Name | Samuel Byron |
Boston | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 May 1885 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm Alfred |
Boston | Father's Surname |
| Father's Occupation | Common Laborer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 31 | Father's Age |
| Mother's Given Name | Huldah Jane | Springer | Mother's Maiden Name |
| Mother's Surname | Boston | McCallsburg Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 32 | 4 | Number of Child This Mother |
| Medical Attendant's Name | S.B. Boston | McCallsburg IA | Medical Attendant's Address |
| Certificate Signer's Name | S.B. Boston | McCallsburg IA | Certificate Signer's Address |
| Returned by Name | S.B. Boston | | |