| Certificate Number | 209 | | Date Issued |
| Child Given Name | Homer |
Shattuck | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 15 Jun 1889 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | L.H. |
Shattuck | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Mary | Bates | Mother's Maiden Name |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | G.D. Soule | Roland IA | Medical Attendant's Address |