| Certificate Number | 400 | | Date Issued |
| Child Given Name | |
Burkhart | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Oct 1886 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Charlie A. |
Burkhart | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Linn Co IA | 26 | Father's Age |
| Mother's Given Name | Sarah E. | Williams | Mother's Maiden Name |
| Mother's Surname | Burkhart | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Lee Co IL | Mother's Birth Place |
| Mother's Age | 18 | 2 | 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 | | |