| Certificate Number | 929 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Mar 1884 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Sylvester |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 29 | Father's Age |
| Mother's Given Name | Sarah Ann | Elliott | Mother's Maiden Name |
| Mother's Surname | Scott | | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 5 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hays | | |