| Certificate Number | 2 | | Date Issued |
| Child Given Name | Carrie Irene |
Myers | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | Lafe |
Myers | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Greedfield Warren Co IA | 21 | Father's Age |
| Mother's Given Name | Mary | Spencer | Mother's Maiden Name |
| Mother's Surname | Myers | Story Co IA | Mother's Residence |
| Mother's Nationality | | Milford Twp Story Co IA | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Abby Penn Miller | Ames IA | Medical Attendant's Address |