| Certificate Number | 296 | | Date Issued |
| Child Given Name | Berince Elmer |
Green | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 20 Apr 1886 |
| Place of Birth |
| Father's Given Name | Jas. B. |
Green | Father's Surname |
| Father's Occupation | Post Master | | Father's Nationality |
| Father's Birth Place | New Jersey | 30 | Father's Age |
| Mother's Given Name | Alma H. | Kerr | Mother's Maiden Name |
| Mother's Surname | Gren | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |