| Certificate Number | 169 | | Date Issued |
| Child Given Name | Rinda |
Jones | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 23 May 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | William A. |
Jones | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 50 | Father's Age |
| Mother's Given Name | Mary Jane | Jones | Mother's Maiden Name |
| Mother's Surname | Jones | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Jefferson Co iA | Mother's Birth Place |
| Mother's Age | 36 | 5 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |