| Certificate Number | 249 | | Date Issued |
| Child Given Name | Don Charles Irving |
Brown | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Aug 1889 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Chas. S. |
Brown | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Canada | 25 | Father's Age |
| Mother's Given Name | Hattie E. | Quigley | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Michigan | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |