| Certificate Number | 869 | | Date Issued |
| Child Given Name | |
Lewis | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 02 Feb 1884 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | E.G. |
Lewis | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 37 | Father's Age |
| Mother's Given Name | Nancy E. | Gilchrist | Mother's Maiden Name |
| Mother's Surname | Lewis | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 25 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.D. Thompson | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | F.D. Thompson | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | F.D. Thompson | | |