| Certificate Number | 639 | | Date Issued |
| Child Given Name | Frederick |
Straub | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Apr 1883 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Albert L. |
Straub | Father's Surname |
| Father's Occupation | Laborer | French | Father's Nationality |
| Father's Birth Place | France | 32 | Father's Age |
| Mother's Given Name | Emma | McDowell | Mother's Maiden Name |
| Mother's Surname | Straub | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 26 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | Brooks | | |