| Certificate Number | 406 | | Date Issued |
| Child Given Name | |
Boston | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Oct 1886 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas |
Boston | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Aggie | Scarrow | Mother's Maiden Name |
| Mother's Surname | Boston | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |