| Certificate Number | 535 | | Date Issued |
| Child Given Name | |
Story | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Jan 1883 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Francis Marion |
Story | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 49 | Father's Age |
| Mother's Given Name | Hannah E. | Keeder | Mother's Maiden Name |
| Mother's Surname | Story | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 39 | 2 | 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. | | |