| Certificate Number | 14 | | Date Issued |
| Child Given Name | Alma |
Proctor | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 13 Jul 1880 |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
Proctor | Father's Surname |
| Father's Occupation | Farmer | Canadian | Father's Nationality |
| Father's Birth Place | Canada | 26 | Father's Age |
| Mother's Given Name | Clista M. | Hoskins | Mother's Maiden Name |
| Mother's Surname | Procter | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Buro Co IL | Mother's Birth Place |
| Mother's Age | 17 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hays | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hays | Cambridge IA | Certificate Signer's Address |
| Returned by Name | 'mail' | | |