| Certificate Number | 761 | | Date Issued |
| Child Given Name | |
McNeiss | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Ontario Story Co IA | Place of Birth |
| Father's Given Name | Wm |
McNeiss | Father's Surname |
| Father's Occupation | Farmer | Irish | Father's Nationality |
| Father's Birth Place | Ireland | 70 | Father's Age |
| Mother's Surname | McNeiss | Ontario Story Co IA | Mother's Residence |
| Mother's Nationality | Irish | Ireland | Mother's Birth Place |
| Mother's Age | 40 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |