| Certificate Number | 631 | | Date Issued |
| Child Given Name | Clarance O. |
Wiggins | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Sep 1887 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | C.F. |
Wiggins | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 30 | Father's Age |
| Mother's Given Name | Emma J. | Stark | Mother's Maiden Name |
| Mother's Surname | Wiggins | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Sycamore IL | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | 'Father' | | Medical Attendant's Address |