| Certificate Number | 611 | | Date Issued |
| Child Given Name | Curt H. |
Will | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Mar 1883 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | John M. |
Will | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Virginia | 38 | Father's Age |
| Mother's Given Name | Harriet E. | Higley | Mother's Maiden Name |
| Mother's Surname | Will | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 36 | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.O., Mrs. Higley | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | B.O., Mrs. Higley | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | B.O., Mrs. Higley | | |