| Certificate Number | 291 | | Date Issued |
| Child Given Name | Carry M. |
Kirk | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 26 Dec 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | James H. |
Kirk | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Kentucky | 49 | Father's Age |
| Mother's Given Name | Elizabeth C. | Warren | Mother's Maiden Name |
| Mother's Surname | Kirk | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 38 | 6 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes M.D. | | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes M.D. | | Certificate Signer's Address |
| Returned by Name | D.D. Hayes M.D. | | |