| Certificate Number | 75 | | Date Issued |
| Child Given Name | |
Rogers | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Jan 1888 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | H.N. |
Rogers | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | St. Lawrence Co NJ | 45 | Father's Age |
| Mother's Given Name | Arvila | Wheeler | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |