| Certificate Number | 919 | | Date Issued |
| Child Given Name | |
John | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Feb 1884 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | James B. |
John | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | | Father's Age |
| Mother's Given Name | Mary E. | Thompson | Mother's Maiden Name |
| Mother's Surname | John | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | | 3 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |