| Certificate Number | 210 | | Date Issued |
| Child Given Name | |
Beedle | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 28 Jul 1881 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | James A. |
Beedle | Father's Surname |
| Father's Occupation | Section Boss | | Father's Nationality |
| Father's Birth Place | Indiana | 25 | Father's Age |
| Mother's Given Name | Mary Emma | Sutter | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 21 | 3 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Meridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Meridith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Meridith | | |