| Certificate Number | 620 | | Date Issued |
| Child Given Name | |
Fields | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 10 Apr 1883 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Jerimiah |
Fields | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Iowa | 26 | Father's Age |
| Mother's Given Name | Henrietta | Noyes | Mother's Maiden Name |
| Mother's Surname | Fields | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell Ia | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |