| Certificate Number | 140 | | Date Issued |
| Child Given Name | |
John | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 May 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Marion E. |
John | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 27 | Father's Age |
| Mother's Given Name | Mary | Bartlett | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell IA | Medical Attendant's Address |