| Certificate Number | 53 | | Date Issued |
| Child Given Name | |
Willits | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Jan 1888 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | F.M. |
Willits | Father's Surname |
| Father's Occupation | Well Digger | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Adalade | Whinnnesy | Mother's Maiden Name |
| Mother's Surname | Willits | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |