| Certificate Number | 213 | | Date Issued |
| Child Given Name | Austin Theodore |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Jun 1889 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | John W. |
Smith | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Nancy J. | McClure | Mother's Maiden Name |
| Mother's Surname | | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 33 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |