| Certificate Number | 162 | | Date Issued |
| Child Given Name | |
Snider | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Jun 1885 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Morris M. |
Snider | Father's Surname |
| Father's Occupation | Miller | American | Father's Nationality |
| Father's Birth Place | Preston Co WV | 41 | Father's Age |
| Mother's Given Name | Dinnah Belle | Wilson | Mother's Maiden Name |
| Mother's Surname | Snider | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 39 | 5 | Number of Child This Mother |
| Medical Attendant's Name | W.H. Grafton M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | W.H. Grafton M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | W.H. Grafton M.D. | | |