| Certificate Number | 20 | | Date Issued |
| Child Given Name | |
Hauser | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 21 Nov 1884 |
Cambridge Story Co IA | Place of Birth |
| Father's Given Name | Jas. H. |
Hauser | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Mary J. | Smith | Mother's Maiden Name |
| Mother's Surname | Hauser | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 22 | | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |