| Certificate Number | 62 | | Date Issued |
| Child Given Name | |
Fair | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 17 Jan 1890 |
| Place of Birth |
| Father's Given Name | John W. |
Fair | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 44 | Father's Age |
| Mother's Given Name | E.D. | Dodge | Mother's Maiden Name |
| Mother's Surname | | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 38 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |