| Certificate Number | 790 | | Date Issued |
| Child Given Name | |
Adams | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Oct 1883 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Daniel |
Adams | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Fannie Belle | Holmes | Mother's Maiden Name |
| Mother's Surname | Adams | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Certificate Signer's Name | George Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | George Stitzell | | |