| Certificate Number | 781 | | Date Issued |
| Child Given Name | Ivan |
Davis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 02 Jul 1883 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Sam R. |
Davis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Wainsburg Green Co PA | 40 | Father's Age |
| Mother's Given Name | Sarah Elliott | Wright | Mother's Maiden Name |
| Mother's Surname | Davis | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Geneva Decalb Co IL | Mother's Birth Place |
| Mother's Age | 30 | 8 | Number of Child This Mother |
| Medical Attendant's Name | F.S., Dr. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S., Dr. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S., Dr. Newton | | |