| Certificate Number | 124 | | Date Issued |
| Child Given Name | Clara |
Mathews | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 05 Feb 1881 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas. |
Mathews | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New Jersey | 38 | Father's Age |
| Mother's Given Name | sarah | Manges | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 27 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Rachel Marshall | Gilbert Station IA | Medical Attendant's Address |
| Certificate Signer's Name | Rachel Marshall | Gilbert Station IA | Certificate Signer's Address |
| Returned by Name | Rachel Marshall | | |