| Certificate Number | 188 | | Date Issued |
| Child Given Name | Mabel Melvina |
Mason | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Sep 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | W.R. |
Mason | Father's Surname |
| Father's Occupation | Stockman | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 37 | Father's Age |
| Mother's Given Name | Emma | Mathews | Mother's Maiden Name |
| Mother's Surname | Mason | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 32 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb M.D. | | |