| Certificate Number | 779 | | Date Issued |
| Child Given Name | |
Willets | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 03 Sep 1883 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | J.H.V. |
Willets | Father's Surname |
| Father's Occupation | Druggist | American | Father's Nationality |
| Father's Birth Place | Indiana | 31 | Father's Age |
| Mother's Given Name | Rosetta | Green | Mother's Maiden Name |
| Mother's Surname | Willets | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |