| Certificate Number | 398 | | Date Issued |
| Child Given Name | Maud |
Miller | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Sep 1886 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Martin |
Miller | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Denmark | 22 | Father's Age |
| Mother's Given Name | Bertha | Peterson | Mother's Maiden Name |
| Mother's Surname | Miller | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 20 | | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |