| Certificate Number | 238 | | Date Issued |
| Child Given Name | John Winters |
Rex | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 29 Jul 1889 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | John C. |
Rex | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 29 | Father's Age |
| Mother's Given Name | Lulu | Winters | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |