| Certificate Number | 248 | | Date Issued |
| Child Given Name | |
Queal | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Sep 1881 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas. |
Queal | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 30 | Father's Age |
| Mother's Given Name | Charlotte | Dany | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 35 | 6 | Number of Child This Mother |
| Medical Attendant's Name | G.H. Merredith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.H. Merredith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.H. Merredith | | |