| Certificate Number | 593 | | Date Issued |
| Child Given Name | Bettie Jane |
Boomer | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Jan 1883 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | John M. |
Boomer | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New Jersey | 32 | Father's Age |
| Mother's Given Name | Martha E. | Banks | Mother's Maiden Name |
| Mother's Surname | Boomer | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | Canadian | Canada | Mother's Birth Place |
| Mother's Age | 29 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |