| Certificate Number | 81 | | Date Issued |
| Child Given Name | M.J. |
See | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Feb 1888 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Johnathan |
See | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Virginia | 69 | Father's Age |
| Mother's Given Name | Mary Ellen | Dawson | Mother's Maiden Name |
| Mother's Surname | See | | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 42 | 11 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |