| Certificate Number | 126 | | Date Issued |
| Child Given Name | |
Shockley | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 29 Jan 1881 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Henry T. |
Shockley | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Henry Co IN | 25 | Father's Age |
| Mother's Given Name | Margaret L. | Cromwell | Mother's Maiden Name |
| Mother's Surname | Shockley | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Boone Co IA | Mother's Birth Place |
| Mother's Age | 18 | 1 | Number of Child This Mother |
| Medical Attendant's Name | N.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | N.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | N.M. Templeton | | |