| Certificate Number | 88 | | Date Issued |
| Child Given Name | Jay |
Born | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jan 1890 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Born | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 46 | Father's Age |
| Mother's Given Name | Marietta | Howe | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Connecticut | Mother's Birth Place |
| Mother's Age | 36 | 9 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |