| Certificate Number | 194 | | Date Issued |
| Child Given Name | |
Stoddard | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
| Place of Birth |
| Father's Given Name | Bruce |
Stoddard | Father's Surname |
| Father's Occupation | Shoemaker | | Father's Nationality |
| Father's Birth Place | | 30 | Father's Age |
| Mother's Given Name | Mary | Stevens | Mother's Maiden Name |
| Mother's Surname | Stoddard | | Mother's Residence |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.R. Myers | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | J.R. Myers | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | J.R. Myers | | |