| Certificate Number | 33 | | Date Issued |
| Child Given Name | Agnes E. |
Spurrier | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 May 1880 |
Grand Junction IA | Place of Birth |
| Father's Given Name | Ralph E. |
Spurrier | Father's Surname |
| Father's Occupation | Hardware dealer | American | Father's Nationality |
| Father's Birth Place | Ohio | 28 | Father's Age |
| Mother's Given Name | Elizabeth | Johnston | Mother's Maiden Name |
| Mother's Surname | Spurrier | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.B., Dr. Park | Grand Junction IA | Medical Attendant's Address |
| Certificate Signer's Name | R.E. Spurrier | Grand Junction IA | Certificate Signer's Address |
| Returned by Name | 'By mail' | | |