| Certificate Number | 215 | | Date Issued |
| Child Given Name | Clandelia B. |
Robinson | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 03 Aug 1881 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | Ge. G. |
Robinson | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 27 | Father's Age |
| Mother's Given Name | Alice | Gregory | Mother's Maiden Name |
| Mother's Surname | Robinson | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |