| Certificate Number | 101 | | Date Issued |
| Child Given Name | Jennie |
Mitchell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Apr 1885 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Alx |
Mitchell | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New York | 40 | Father's Age |
| Mother's Given Name | Augustie | Peabody | Mother's Maiden Name |
| Mother's Surname | Mitchell | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I. Hostetter | | |