| Certificate Number | 141 | | Date Issued |
| Child Given Name | |
Widener | Child Surname |
| Child Sex | Male |
A | Child Race |
| Date of Birth | 28 Mar 1881 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | J. |
Widener | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 53 | Father's Age |
| Mother's Given Name | Sarah | Beechley | Mother's Maiden Name |
| Mother's Surname | Widener | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 40 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |