| Certificate Number | 308 | | Date Issued |
| Child Given Name | Nina Annetta |
Starr | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 11 Jan 1882 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Samuel Jackson |
Starr | Father's Surname |
| Father's Occupation | Physician | American | Father's Nationality |
| Father's Birth Place | Indiana | 46 | Father's Age |
| Mother's Given Name | Rose Marion | Frasee | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Vermont | Mother's Birth Place |
| Mother's Age | 37 | 5 | Number of Child This Mother |
| Medical Attendant's Name | S.J. Starr M.D. | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | S.J. Starr M.D. | Ames IA | Certificate Signer's Address |
| Returned by Name | S.J. Starr M.D. | | |