| Certificate Number | 64 | | Date Issued |
| Child Given Name | Geo. Elias |
Apple | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Dec 1883 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Clark |
Apple | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Center Grove IA | 26 | Father's Age |
| Mother's Given Name | Cornella | Hyden | Mother's Maiden Name |
| Mother's Surname | Apple | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Richland Twp | Mother's Birth Place |
| Mother's Age | 22 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.E. Scott | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.E. Scott | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.E. Scott | | |