| Certificate Number | 328 | | Date Issued |
| Child Given Name | |
Weatherly | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 06 Jun 1886 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Daniel E. |
Weatherly | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Orrin Co IN | 47 | Father's Age |
| Mother's Given Name | Mary Ann | Miller | Mother's Maiden Name |
| Mother's Surname | Weatherly | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Des Moines Polk Co IA | Mother's Birth Place |
| Mother's Age | 37 | 5 | 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 | | |