| Certificate Number | 33 | | Date Issued |
| Child Given Name | |
Outwater | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Dec 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Lucius |
Outwater | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Father's Birth Place | New York | 35 | Father's Age |
| Mother's Given Name | Lucy E. | Dix | Mother's Maiden Name |
| Mother's Surname | Outwater | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 37 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |