| Certificate Number | 323 | | Date Issued |
| Child Given Name | Florence Queen |
Burkhart | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 18 Dec 1881 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | John C. |
Burkhart | Father's Surname |
| Father's Occupation | Lumber Dealer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 48 | Father's Age |
| Mother's Given Name | Anna Mary | Albaugh | Mother's Maiden Name |
| Mother's Surname | Burkhart | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 41 | 8 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Mead & Hone | | Medical Attendant's Address |
| Certificate Signer's Name | J.C. Burkhart | | Certificate Signer's Address |
| Returned by Name | J.C. Burkhard | | |