| Certificate Number | 650 | | Date Issued |
| Child Given Name | |
Rice | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Jun 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Carter |
Rice | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Illinois | 26 | Father's Age |
| Mother's Given Name | Hattie | Maxwell | Mother's Maiden Name |
| Mother's Surname | Rice | | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 22 | 3 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Merideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Merideth | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Merideth | | |