| Certificate Number | 79 | | Date Issued |
| Child Given Name | |
Stares | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 12 Nov 1880 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | George W. |
Stares | Father's Surname |
| Father's Occupation | Teamster | American | Father's Nationality |
| Father's Birth Place | Linn Co IA | 28 | Father's Age |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Linn Co IA | Mother's Birth Place |
| Mother's Age | | 3 | Number of Child This Mother |
| Medical Attendant's Name | James Bradly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | James Bradly | Ames IA | Certificate Signer's Address |
| Returned by Name | James Bradly | | |