| Certificate Number | 610 | | Date Issued |
| Child Given Name | |
Funk | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 Apr 1883 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Frank C. |
Funk | Father's Surname |
| Father's Occupation | Carpenter | American | Father's Nationality |
| Father's Birth Place | Iowa Center Story Co IA | 26 | Father's Age |
| Mother's Given Name | Eliza Ann | Berlin | Mother's Maiden Name |
| Mother's Surname | Funk | | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.O. Higley | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | B.O. Higley | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | B.O. Higley | | |