| Certificate Number | 12 | | Date Issued |
| Child Given Name | |
Farrington | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 26 Oct 1889 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | A. Leroy |
Farrington | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Howard Co IN | 28 | Father's Age |
| Mother's Given Name | Fanny B. | Shugart | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Bureau Co IL | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.D. Chamberlin | Nevada IA | Medical Attendant's Address |