| Certificate Number | 317 | | Date Issued |
| Child Given Name | Stella A. |
Pool | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 01 Jan 1882 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Butler |
Pool | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Mother's Given Name | C. | Bryant | Mother's Maiden Name |
| Mother's Surname | Pool | | Mother's Residence |
| Mother's Age | | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.B. Richards M.D. | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | G.B. Richards M.D. | Nevada IA | Certificate Signer's Address |
| Returned by Name | G.B. Richards M.D. | | |