| Certificate Number | 788 | | Date Issued |
| Child Given Name | George V. |
Chapman | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Oct 1883 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | F.J. |
Chapman | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Wisconson | 29 | Father's Age |
| Mother's Given Name | Laura | Kindlespire | Mother's Maiden Name |
| Mother's Surname | Chapman | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | George Stitzell | Nevada IA | Medical Attendant's Address |