| Certificate Number | 183 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 28 May 1881 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | David |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 22 | Father's Age |
| Mother's Given Name | Alice G. | Phillip | Mother's Maiden Name |
| Mother's Surname | Scott | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Michigan | Mother's Birth Place |
| Mother's Age | 18 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |