| Certificate Number | 1059 | | Date Issued |
| Child Given Name | George Washington |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Aug 1884 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Johnathan |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 46 | Father's Age |
| Mother's Given Name | Mary | Smay | Mother's Maiden Name |
| Mother's Surname | Smith | Warren Twp Story Co IA | Mother's Residence |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |