| Certificate Number | 524 | | Date Issued |
| Child Given Name | |
Baston | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Apr 1887 |
McCallsburg Story Co IA | Place of Birth |
| Father's Given Name | J.E. |
Baston | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 21 | Father's Age |
| Mother's Given Name | P.J. | Hendrickson | Mother's Maiden Name |
| Mother's Surname | Baston | McCallsburg Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |