| Certificate Number | 333 | | Date Issued |
| Child Given Name | Mildred Maria |
McGooden | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Aug 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Samuel |
McGooden | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 25 | Father's Age |
| Mother's Given Name | Retta | Nichols | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |