| Certificate Number | 442 | | Date Issued |
| Child Given Name | Anson |
Chamberlin | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 27 Aug 1882 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Alva |
Chamberlin | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 36 | Father's Age |
| Mother's Given Name | Lavinia | Baird | Mother's Maiden Name |
| Mother's Surname | Chamberlin | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 32 | | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hays M.D. | | |