| Certificate Number | 1 | | Date Issued |
| Child Given Name | Emory |
Dillon | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 11 Sep 1888 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | C.W. |
Dillon | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iron Hill IA | 31 | Father's Age |
| Mother's Given Name | Eucy C. | Ewing | Mother's Maiden Name |
| Mother's Surname | | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Celia A. Moore | Lawrence IA | Medical Attendant's Address |