| Certificate Number | 11 | | Date Issued |
| Child Given Name | Henry F. |
Chitty | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 28 Oct 1889 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | J.C. |
Chitty | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 27 | Father's Age |
| Mother's Given Name | Bell | Murphy | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.I. Hostetter | Colo IA | Medical Attendant's Address |