| Child Given Name | William Green |
Allen | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 12 Sep 1890 |
Story County IA | Place of Birth |
| Father's Given Name | Geo Washington |
Allen | Father's Surname |
| Father's Occupation | farming | American | Father's Nationality |
| Father's Birth Place | Marshall Co IA | 33 | Father's Age |
| Mother's Given Name | Harriett Everett | Copeland | Mother's Maiden Name |
| Mother's Nationality | American | Logan Co IL | Mother's Birth Place |
| Mother's Age | 22 | | Number of Child This Mother |
| Medical Attendant's Name | Dr. Sole | | Medical Attendant's Address |
| Certificate Signer's Name | Harriett Smith | | Certificate Signer's Address |