| Certificate Number | 528 | | Date Issued |
| Child Given Name | |
Rich | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Mar 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | O.P. |
Rich | Father's Surname |
| Father's Occupation | Barber | | Father's Nationality |
| Father's Birth Place | Indiana | 29 | Father's Age |
| Mother's Given Name | Nettie | Shattuck | Mother's Maiden Name |
| Mother's Surname | Rich | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |