| Certificate Number | 103 | | Date Issued |
| Child Given Name | |
Fonks | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 22 Feb 1885 |
Boone Co IA | Place of Birth |
| Father's Given Name | C.A. |
Fonks | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 28 | Father's Age |
| Mother's Given Name | L. | Crane | Mother's Maiden Name |
| Mother's Surname | | Boone Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |