| Certificate Number | 65 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Jan 1889 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank E. |
Scott | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 23 | Father's Age |
| Mother's Given Name | Carrie | Hoskins | Mother's Maiden Name |
| Mother's Surname | | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |