| Certificate Number | 210 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 09 Jul 1889 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Sylvester |
Scott | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 35 | Father's Age |
| Mother's Given Name | Sarah A. | Elliott | Mother's Maiden Name |
| Mother's Surname | | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 33 | 7 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |