| Certificate Number | 86 | | Date Issued |
| Child Given Name | |
Wood | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Sep 1880 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | C. |
Wood | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 26 | Father's Age |
| Mother's Given Name | Rose | | Mother's Maiden Name |
| Mother's Surname | Wood | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Geo P. Johnston | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo P. Johnston | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Geo P. Johnston | | |