| Certificate Number | 240 | | Date Issued |
| Child Given Name | Frederick L. |
Wilson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | John P. |
Wilson | Father's Surname |
| Father's Occupation | Teaming & Draying | American | Father's Nationality |
| Father's Birth Place | Ohio | 31 | Father's Age |
| Mother's Given Name | Emley A. | Child | Mother's Maiden Name |
| Mother's Surname | Wilson | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | American | New Hampshire | Mother's Birth Place |
| Mother's Age | 28 | 6 | Number of Child This Mother |
| Medical Attendant's Name | E., Mrs. Cook | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E., Mrs. Cook | Nevada IA | Certificate Signer's Address |
| Returned by Name | E., Mrs. Cook | | |