| Certificate Number | 161 | | Date Issued |
| Child Given Name | |
Bean | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 24 Mar 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Cyrus P. |
Bean | Father's Surname |
| Father's Occupation | Drayman | | Father's Nationality |
| Father's Birth Place | Kane Co IL | 32 | Father's Age |
| Mother's Given Name | | Brown | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |