| Certificate Number | 407 | | Date Issued |
| Child Given Name | |
Mead | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 28 Jun 1882 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Chas W. |
Mead | Father's Surname |
| Father's Occupation | Stock Dealer | American | Father's Nationality |
| Father's Birth Place | Illinois | 26 | Father's Age |
| Mother's Given Name | Mary A. | Woodward | Mother's Maiden Name |
| Mother's Surname | Mead | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | R.C. Alexander M.D. | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | R.C. Alexander M.D. | Collins IA | Certificate Signer's Address |
| Returned by Name | R.C. Alexander M.D. | | |