| Certificate Number | 115 | | Date Issued |
| Child Given Name | |
Kaness | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Mar 1888 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Kaness | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 44 | Father's Age |
| Mother's Given Name | Mary A. | Bates | Mother's Maiden Name |
| Mother's Surname | | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Michigan | Mother's Birth Place |
| Mother's Age | 36 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |