| Certificate Number | 178 | | Date Issued |
| Child Given Name | |
Livingston | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Oct 1885 |
| Place of Birth |
| Father's Given Name | M. Eugene |
Livingston | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 24 | Father's Age |
| Mother's Given Name | Elizabeth | Green | Mother's Maiden Name |
| Mother's Surname | Livingston | Cambridge Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 21 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.W. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.W. Brown | | |