| Certificate Number | 523 | | Date Issued |
| Child Given Name | |
Henderson | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 22 Nov 1882 |
At J.C. Lee Residence Story Co IA | Place of Birth |
| Father's Given Name | Ben |
Henderson | Father's Surname |
| Father's Occupation | Farmer | Norwegian | Father's Nationality |
| Father's Birth Place | Norway | 27 | Father's Age |
| Mother's Given Name | Mary Jane | Lee | Mother's Maiden Name |
| Mother's Surname | Henderson | Hamilton Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |