| Certificate Number | 691 | | Date Issued |
| Child Given Name | |
Cunningham | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 19 Jun 1883 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Cunningham | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 25 | Father's Age |
| Mother's Given Name | Addie | Stevens | Mother's Maiden Name |
| Mother's Surname | Cunningham | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |