| Certificate Number | 477 | | Date Issued |
| Child Given Name | Leota |
Pool | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Jan 1887 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Butler |
Pool | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 30 | Father's Age |
| Mother's Given Name | Hannah | Bryant | Mother's Maiden Name |
| Mother's Surname | Pool | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |