| Certificate Number | 394 | | Date Issued |
| Child Given Name | |
Barns | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 31 Aug 1886 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Ira |
Barns | Father's Surname |
| Father's Occupation | Grain Merchant | | Father's Nationality |
| Father's Birth Place | Ohio | 52 | Father's Age |
| Mother's Given Name | Etta M. | Morrisy | Mother's Maiden Name |
| Mother's Surname | Barns | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Michigan | Mother's Birth Place |
| Mother's Age | 42 | 4 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |