| Certificate Number | 306 | | Date Issued |
| Child Given Name | |
Golden | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 30 Sep 1889 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | A.L. |
Golden | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Story Co IA | 29 | Father's Age |
| Mother's Given Name | Jennie | Funk | Mother's Maiden Name |
| Mother's Surname | | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |