| Certificate Number | 223 | | Date Issued |
| Child Given Name | |
Keel | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Aug 1888 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Chas. W. |
Keel | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 24 | Father's Age |
| Mother's Given Name | Eva | Tomkins | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell IA | Medical Attendant's Address |