| Certificate Number | 632 | | Date Issued |
| Child Given Name | |
Bartine | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Liberty Twp Marshall Co IA | Place of Birth |
| Father's Given Name | Ammos A. |
Bartine | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 49 | Father's Age |
| Mother's Given Name | Lovinia A. | Vandeneuter | Mother's Maiden Name |
| Mother's Surname | Bartine | Marshall Co IA | Mother's Residence |
| Mother's Nationality | American | Virginia | Mother's Birth Place |
| Mother's Age | 35 | 7 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |