| Certificate Number | 913 | | Date Issued |
| Child Given Name | |
Person | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Apr 1884 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | C.E. |
Person | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Massachusets | 32 | Father's Age |
| Mother's Given Name | Ellen | Kirk | Mother's Maiden Name |
| Mother's Surname | Person | Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 31 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Phoebe Hopkins | Story Co IA | Medical Attendant's Address |
| Certificate Signer's Name | Phoebe Hopkins | Story Co IA | Certificate Signer's Address |
| Returned by Name | Phoebe Hopkins | | |