| Certificate Number | 236 | | Date Issued |
| Child Given Name | Clara |
Pepper | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 May 1890 |
Zenorville Story Co IA | Place of Birth |
| Father's Given Name | William |
Pepper | Father's Surname |
| Father's Occupation | Farmer & Foot racer | | Father's Nationality |
| Father's Birth Place | Iowa | 30 | Father's Age |
| Mother's Given Name | Edna | Carey | Mother's Maiden Name |
| Mother's Surname | | Montgomery Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |