| Certificate Number | 12 | | Date Issued |
| Child Given Name | |
Green | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 13 Aug 184 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | James B. |
Green | Father's Surname |
| Father's Occupation | Restaurant Keeper | | Father's Nationality |
| Father's Birth Place | New Jersey | 28 | Father's Age |
| Mother's Given Name | Alma H. | Kerr | Mother's Maiden Name |
| Mother's Surname | Green | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |