| Certificate Number | 455 | | Date Issued |
| Child Given Name | Claud |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Sep 1882 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Jack |
Smith | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 30 | Father's Age |
| Mother's Given Name | Martha | Whitinger | Mother's Maiden Name |
| Mother's Surname | Smith | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.O., Mrs. Higley | | Medical Attendant's Address |