| Certificate Number | 81 | | Date Issued |
| Child Given Name | |
Bates | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Feb 1884 |
Walnut Grove | Place of Birth |
| Father's Given Name | Sylvester F. |
Bates | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Michigan | 28 | Father's Age |
| Mother's Given Name | Betty Jane | Harrison | Mother's Maiden Name |
| Mother's Surname | Bates | Walnut Grove | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb M.D. | | |