| Certificate Number | 191 | | Date Issued |
| Child Given Name | Mary Eva |
Rex | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Nov 1885 |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | John C. |
Rex | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 25 | Father's Age |
| Mother's Given Name | Luella | Winters | Mother's Maiden Name |
| Mother's Surname | | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |