| Certificate Number | 629 | | Date Issued |
| Child Given Name | Howard |
Warner | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 May 1883 |
Center Grove IA | Place of Birth |
| Father's Given Name | A.J. |
Warner | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | California | 35 | Father's Age |
| Mother's Given Name | Emma | Grosclose | Mother's Maiden Name |
| Mother's Surname | Warner | Center Grove IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | 5 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |