| Certificate Number | 509 | | Date Issued |
| Child Given Name | |
Rice | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Feb 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Carter |
Rice | Father's Surname |
| Father's Occupation | Well Digger | | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Hattie M. | Maxwell | Mother's Maiden Name |
| Mother's Surname | Rice | | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 25 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |