| Certificate Number | 402 | | Date Issued |
| Child Given Name | Flossia |
Jones | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Zach |
Jones | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 32 | Father's Age |
| Mother's Given Name | Bell | Guge | Mother's Maiden Name |
| Mother's Surname | Jones | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Miss. | Mother's Birth Place |
| Mother's Age | 27 | 5 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merredith M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merredith M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merredith M.D. | | |