| Certificate Number | 644 | | Date Issued |
| Child Given Name | |
French | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 01 Jun 1883 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | William H. |
French | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | C.A. | Vincent | Mother's Maiden Name |
| Mother's Surname | French | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 36 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Lewis Schooler | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Lewis Schooler | Nevada IA | Certificate Signer's Address |
| Returned by Name | Lewis Schooler | | |