| Certificate Number | 215 | | Date Issued |
| Child Given Name | Fanny M. |
Moore | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Nov 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John |
Moore | Father's Surname |
| Father's Occupation | Auditor C, on w. Ry | | Father's Nationality |
| Father's Birth Place | Michigan | 30 | Father's Age |
| Mother's Given Name | May L. | Helen | Mother's Maiden Name |
| Mother's Surname | Moore | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |