| Certificate Number | 168 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Samuel R. |
Davis | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Green Co PA | 42 | Father's Age |
| Mother's Given Name | Sarah E. | Wright | Mother's Maiden Name |
| Mother's Surname | Davis | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 9 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |