| Certificate Number | 112 | | Date Issued |
| Child Given Name | |
Meyers | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Mar 1885 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Uris |
Meyers | Father's Surname |
| Father's Occupation | Livery Man | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 31 | Father's Age |
| Mother's Given Name | Lizzie C. | Wood | Mother's Maiden Name |
| Mother's Surname | Meyers | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 23 | 4 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Maxwell IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Maxwell IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |