| Certificate Number | 617 | | Date Issued |
| Child Given Name | |
McVey | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Apr 1883 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Shell |
McVey | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | Nancy | Hostclaw | Mother's Maiden Name |
| Mother's Surname | McVey | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 30 | 3 | 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 | | |