| Certificate Number | 190 | | Date Issued |
| Child Given Name | Roy O. |
Yazel | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 May 1889 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | David |
Yazel | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wisconson | 47 | Father's Age |
| Mother's Given Name | Lucinda | Skidmore | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 21 | 11 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |