| Certificate Number | 173 | | Date Issued |
| Child Given Name | Alva T. |
Gross | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 05 Oct 1885 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Edwin |
Gross | Father's Surname |
| Father's Occupation | Clerk | | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Esther | Thurston | Mother's Maiden Name |
| Mother's Surname | Gross | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |