| Certificate Number | 49 | | Date Issued |
| Child Given Name | Lillie May |
Pickett | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Aug 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | J.H. |
Pickett | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | May | Ayer | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |