| Certificate Number | 415 | | Date Issued |
| Child Given Name | |
Simpson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Aug 1882 |
Grant Twp Hardin Co IA | Place of Birth |
| Father's Given Name | Edward |
Simpson | Father's Surname |
| Father's Occupation | Farmer | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 29 | Father's Age |
| Mother's Given Name | Elva | Crain | Mother's Maiden Name |
| Mother's Surname | Simpson | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New Hampshire | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton M.D. | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |