| Certificate Number | 93 | | Date Issued |
| Child Given Name | Blanche |
Willitts | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Mar 1885 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | J.H.V. |
Willitts | Father's Surname |
| Father's Occupation | Druggist | American | Father's Nationality |
| Father's Birth Place | Indiana | 32 | Father's Age |
| Mother's Given Name | Rosella | Greene | Mother's Maiden Name |
| Mother's Surname | Willitts | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |