| Certificate Number | 392 | | Date Issued |
| Child Given Name | Roy Ewing |
Dillion | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Charley W. |
Dillon | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Jackson Co IA | 29 | Father's Age |
| Mother's Given Name | Eucy C. | Ewing | Mother's Maiden Name |
| Mother's Surname | Dillon | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | DeKalb Co IL | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Cilia A. Moore | Decatur Co IA | Medical Attendant's Address |
| Certificate Signer's Name | Cilia A. Moore | Decatur Co IA | Certificate Signer's Address |
| Returned by Name | Cilia A. Moore | | |