| Certificate Number | 785 | | Date Issued |
| Child Given Name | Jerremiah P. |
Chance | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 04 Oct 1883 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Johnathan |
Chance | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 44 | Father's Age |
| Mother's Given Name | Sarah | Pope | Mother's Maiden Name |
| Mother's Surname | Chance | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 33 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Wood | Zearing IA | Medical Attendant's Address |
| Returned by Name | A.W. Brooks | | |