| Certificate Number | 202 | | Date Issued |
| Child Given Name | |
Wayner | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 14 Jul 1881 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Wayner | Father's Surname |
| Father's Occupation | Farming | Dutch | Father's Nationality |
| Father's Birth Place | Pennsylvania | 54 | Father's Age |
| Mother's Given Name | Susan | Brubaker | Mother's Maiden Name |
| Mother's Surname | Wayner | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | Dutch | Virginia | Mother's Birth Place |
| Mother's Age | 39 | 10 | Number of Child This Mother |
| Medical Attendant's Name | B.O., Mrs. Heigley | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | B.O., Mrs. Heigley | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | B.O., Mrs. Heigley | | |