| Certificate Number | 287 | | Date Issued |
| Child Given Name | Frederic Orr |
Glen | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Abram. George |
Glenn | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Martha Bell | Orr | Mother's Maiden Name |
| Mother's Surname | Glenn | | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 31 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Sanford | | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Monk M.D. | | Certificate Signer's Address |
| Returned by Name | E.H. Monk, M.D. | | |