| Certificate Number | 719 | | Date Issued |
| Child Given Name | John |
Holm | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 23 Mar 1881 |
Howard Twp Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Holm | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Ellen | Raymond | Mother's Maiden Name |
| Mother's Surname | Holm | Howard Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Munk | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | E.H. Munk | Nevada IA | Certificate Signer's Address |
| Returned by Name | E.H. Munk | | |