| Certificate Number | 416 | | Date Issued |
| Child Given Name | John F. |
Gilmore | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 21 Aug 1882 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Gilmore | Father's Surname |
| Father's Occupation | Farmer | Irishman | Father's Nationality |
| Father's Birth Place | Ireland | 50 | Father's Age |
| Mother's Given Name | Liza | Bartin | Mother's Maiden Name |
| Mother's Surname | Gilmore | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Irishman | Ireland | Mother's Birth Place |
| Mother's Age | 36 | 6 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |