| Certificate Number | 360 | | Date Issued |
| Child Given Name | |
Koons | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Sep 1889 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Elmer E. |
Koons | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Tennessee | 23 | Father's Age |
| Mother's Given Name | Flora | Berry | Mother's Maiden Name |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G. Stitzell | Nevada IA | Medical Attendant's Address |