| Certificate Number | 410 | | Date Issued |
| Child Given Name | |
Baldis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Oct 1886 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Baldis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 32 | Father's Age |
| Mother's Given Name | Bertha 'Betsey' | Gross | Mother's Maiden Name |
| Mother's Surname | Baldis | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |