| Certificate Number | 192 | | Date Issued |
| Child Given Name | |
Minkins | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 23 Jun 1881 |
Grant Twp Hardin Co IA | Place of Birth |
| Father's Given Name | James |
Minkins | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Mary Rebecca | Fish | Mother's Maiden Name |
| Mother's Surname | Minkins | Grant Twp Hardin Co IA | Mother's Residence |
| Mother's Nationality | American | Connecticut | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Lincoln Twp IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Lincoln Twp IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |