The form is bilingual, in German and Polish. I only translate the German parts, I guess the Polish parts of the form will be the same. I try to decipher the handwriting, and indicate where I am not sure.
- [day missing]
- "Jänner" (austrian for "January")
- "Jaśien" [This could refer to one of the several places currently named Jaśien, some of which are in the formerly Austrian part of southern Poland]. The letter "ś" is Polish; see here.
and these lines are repeated:
- "60" (this is the street/house number: the correspondent column header reads [Hau]"s-Nr." / "Nr. domu")
The column entries read:
- Name des Kindes [name of the child]: Isaak
- Geschlecht [sex]: männlich [male]
- Eheliche, angeblich eheliche oder uneheliche Geburt [Legitmate, allegedly legitimate or illegitimate birth]: unehelich [illegitimate, i.e. the parents have not been married]
- Vor- und Zuname des Vaters, sowie Stand, Beschäftigung und Wohnort [first and last name of the father, marital status, profession and residence]: Efraim Samuel Epstein ledig Schenker in Jaśien [Efraim Samuel Epstein not-married innkeeper in Jaśien]
The titles of the first two large columns (no. 2-3) are largely missing, but it's safe to assume that the first one records the birth date and the second one the date of inscription in the birth registry. (Entries in a birth register are also assigned a sequence number, or another unique identifier. This will have been in the narrow column no. 1, which is completely illegible due to damage.)
The birth certificate was certainly issued in Galicia. This is indicated by the fact that the doucument is bilingual (German / Polish) and the word "Jänner" is typical Austrian; therefore it can be concluded that it was used in the part of Austria-Hungary with a substantial Polish population share. The place "Jaśien" is probably located in one of the regions Kałusz or Brzesko.
The profession "Schenker" can mean "Schankwirt" [inn-keeper] or "Schankkellner" [barman / waiter]. See here.