| Certificate Number | 214 | | Date Issued |
| Child Given Name | Lester |
Belden | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Jul 1888 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Chas. |
Belden | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 36 | Father's Age |
| Mother's Given Name | Addie | Norton | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 2 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |