| Certificate Number | 66 | | Date Issued |
| Child Given Name | |
Miller | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Nov 1887 |
Sheldahl Story Co IA | Place of Birth |
| Father's Given Name | W.B. |
Miller | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | New York | 35 | Father's Age |
| Mother's Given Name | Sue Ellen | Hartman | Mother's Maiden Name |
| Mother's Surname | | Sheldahl Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Anderson | Sheldahl IA | Medical Attendant's Address |