| Certificate Number | 512 | | Date Issued |
| Child Given Name | |
Wyatt | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 07 Nov 1882 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | William |
Wyatt | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 24 | Father's Age |
| Mother's Given Name | Annah Ellen | Boston | Mother's Maiden Name |
| Mother's Surname | Wyatt | Warren Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Sarah B. Boston | Warren Twp IA | Medical Attendant's Address |
| Certificate Signer's Name | Sarah B. Boston | Warren Twp IA | Certificate Signer's Address |
| Returned by Name | Sarah B. Boston | | |