| Certificate Number | 508 | | Date Issued |
| Child Given Name | |
Whitemore | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Nov 1882 |
| Place of Birth |
| Father's Given Name | J.W. |
Whitmore | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Surname | Whitemore | Collins Twp Story Co IA | Mother's Residence |
| Mother's Age | | 5 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |