| Certificate Number | 787 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Oct 1883 |
Polk Co IA | Place of Birth |
| Father's Given Name | W.B. |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 34 | Father's Age |
| Mother's Given Name | Laura J. | Reed | Mother's Maiden Name |
| Mother's Surname | Scott | Polk Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 34 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |