| Certificate Number | 516 | | Date Issued |
| Child Given Name | |
Mosher | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 03 Mar 1887 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | A.E. |
Mosher | Father's Surname |
| Father's Occupation | Minister | | Father's Nationality |
| Father's Birth Place | Wisconson | 26 | Father's Age |
| Mother's Given Name | Frankie A. | Staley | Mother's Maiden Name |
| Mother's Surname | Mosher | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |