| Certificate Number | 116 | | Date Issued |
| Child Given Name | Mabel |
McQuillen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Apr 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
McQuillen | Father's Surname |
| Father's Occupation | Barber | | Father's Nationality |
| Father's Birth Place | Indiana | 36 | Father's Age |
| Mother's Given Name | Ella | McCowin | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 27 | 6 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell IA | Medical Attendant's Address |