| Certificate Number | 84 | | Date Issued |
| Child Given Name | |
Hiatt | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Nov 1889 |
Ontario Story Co IA | Place of Birth |
| Father's Given Name | Lewis N. |
Hiatt | Father's Surname |
| Father's Occupation | R.R. Agent | German | Father's Nationality |
| Father's Birth Place | Indiana | 25 | Father's Age |
| Mother's Given Name | Violet | Hathoway | Mother's Maiden Name |
| Mother's Surname | | Ontario Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |