| Certificate Number | 109 | | Date Issued |
| Child Given Name | Arthur Henry |
Bruner | Child Surname |
| Child Sex | Male |
| Child Race |
| Date of Birth | 04 Jan 1881 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Bruner | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 38 | Father's Age |
| Mother's Given Name | | Flickinger | Mother's Maiden Name |
| Mother's Surname | Bruner | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 34 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Geo P. Johnston | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo P. Johnston | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | Geo P. Johnston | | |