| Certificate Number | 403 | | Date Issued |
| Child Given Name | |
Wilcox | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 03 Jul 1882 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Jas. W. |
Wilcox | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 26 | Father's Age |
| Mother's Given Name | Ella | Kingberg | Mother's Maiden Name |
| Mother's Surname | Wilcox | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Meridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Meridith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Meridith | | |