| Certificate Number | 195 | | Date Issued |
| Child Given Name | Susie May |
Kirkendall | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 31 May 1881 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Eli |
Kirkendall | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Holmes Co OH | 27 | Father's Age |
| Mother's Given Name | Eliza A. | Golden | Mother's Maiden Name |
| Mother's Surname | Kirkendall | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 29 | 3 | Number of Child This Mother |
| Medical Attendant's Name | P.W. Farrar | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | P.W. Farrar | Nevada IA | Certificate Signer's Address |
| Returned by Name | P.W. Farrar | | |