| Certificate Number | 958 | | Date Issued |
| Child Given Name | Cora M. |
Hayes | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Jun 1884 |
Zearing Story Co iA | Place of Birth |
| Father's Given Name | Chas. Eugene |
Hayes | Father's Surname |
| Father's Occupation | Telegraph Operator | American | Father's Nationality |
| Father's Birth Place | Wisconson | 30 | Father's Age |
| Mother's Given Name | Anna Bell | Fiscus | Mother's Maiden Name |
| Mother's Surname | Hayes | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 16 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |