| Certificate Number | 60 | | Date Issued |
| Child Given Name | |
Storm | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Jan 1885 |
Story Co IA | Place of Birth |
| Father's Given Name | J.W. |
Storm | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 35 | Father's Age |
| Mother's Given Name | Emma A. | Mason | Mother's Maiden Name |
| Mother's Surname | Storm | Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 35 | 4 | 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 | | |