| Certificate Number | 770 | | Date Issued |
| Child Given Name | |
Corkins | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Sep 1883 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Corkins | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 41 | Father's Age |
| Mother's Given Name | Cynthia A. | Van Scoy | Mother's Maiden Name |
| Mother's Surname | Corkins | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 36 | 5 | Number of Child This Mother |
| Medical Attendant's Name | S. Bradley | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | S. Bradley | Ames IA | Certificate Signer's Address |
| Returned by Name | S. Bradley | | |