| Certificate Number | 35 | | Date Issued |
| Child Given Name | |
Green | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 08 Nov 1887 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | C.W. |
Green | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | Susan | Smith | Mother's Maiden Name |
| Mother's Surname | Green | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |