| Certificate Number | 296 | | Date Issued |
| Child Given Name | |
Belt | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 19 Jun 1889 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Edward |
Belt | Father's Surname |
| Father's Occupation | Carpenter | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Annie | Hostclaw | Mother's Maiden Name |
| Mother's Surname | | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |