| Certificate Number | 204 | | Date Issued |
| Child Given Name | Cora Clarence |
Chaffin | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Thomas |
Chaffin | Father's Surname |
| Father's Occupation | Farmer | U.S. | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Fannie | Chaplin | Mother's Maiden Name |
| Mother's Surname | Chaffin | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | U.S. | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |