| Certificate Number | 587 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Mar 1883 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Hugh B. |
Smith | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 28 | Father's Age |
| Mother's Given Name | Lizzie J. | McCreery | Mother's Maiden Name |
| Mother's Surname | Smith | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |