| Certificate Number | 157 | | Date Issued |
| Child Given Name | |
Heacock | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | W.H. |
Heacock | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 51 | Father's Age |
| Mother's Given Name | Irena A. | Bonebrake | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 41 | 12 | Number of Child This Mother |
| Medical Attendant's Name | A. Richmond | Ames IA | Medical Attendant's Address |