| Certificate Number | 110 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Mar 1890 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | John C. |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 31 | Father's Age |
| Mother's Given Name | Mary J. | Montgomery | Mother's Maiden Name |
| Mother's Surname | | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Canada | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg | Medical Attendant's Address |