| Certificate Number | 540 | | Date Issued |
| Child Given Name | |
Allen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Jan 1883 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | John F. |
Allen | Father's Surname |
| Father's Occupation | School Teacher | American | Father's Nationality |
| Father's Birth Place | Indiana | 35 | Father's Age |
| Mother's Given Name | Adda | Shoop | Mother's Maiden Name |
| Mother's Surname | Allen | Iowa Center Story Co IA | Mother's Residence |
| Mother's Age | | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.O., Mrs. Higley | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | B.O., Mrs. Higley | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | B.O., Mrs. Higley | | |