| Certificate Number | 21 | | Date Issued |
| Child Given Name | |
Gilbert | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 18 Oct 1889 |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | F.B. |
Gilbert | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Wisconson | 37 | Father's Age |
| Mother's Given Name | Mary A. | Cook | Mother's Maiden Name |
| Mother's Surname | | Gilbert Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 36 | 7 | Number of Child This Mother |
| Medical Attendant's Name | Rachel Marshall | Gilbert Station IA | Medical Attendant's Address |