| Certificate Number | 616 | | Date Issued |
| Child Given Name | |
Burt | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 13 Apr 1883 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | G.S. |
Burt | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | | Patton | Mother's Maiden Name |
| Mother's Surname | Burt | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 29 | 4 | Number of Child This Mother |
| Medical Attendant's Name | N.W. Knepper | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | N.W. Knepper | Collins IA | Certificate Signer's Address |
| Returned by Name | N.W. Knepper | | |