| Certificate Number | 432 | | Date Issued |
| Child Given Name | |
Meyers | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Aug 1886 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Urias |
Meyers | Father's Surname |
| Father's Occupation | Livery Man | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 32 | Father's Age |
| Mother's Given Name | Elizabeth | Good | Mother's Maiden Name |
| Mother's Surname | Meyers | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 22 | 5 | 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 | | |