| Certificate Number | 165 | | Date Issued |
| Child Given Name | |
Perkins | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Apr 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Albert M. |
Perkins | Father's Surname |
| Father's Occupation | Grocer | | Father's Nationality |
| Father's Birth Place | Boone Co IN | 32 | Father's Age |
| Mother's Given Name | Susie | Daniels | 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 | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |