| Certificate Number | 386 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
Ontario Story Co IA | Place of Birth |
| Father's Given Name | Hiram |
Scott | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | Ohio | 45 | Father's Age |
| Mother's Given Name | Lyddie | Estlake | Mother's Maiden Name |
| Mother's Surname | Scott | Ontario Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 36 | 9 | Number of Child This Mother |
| Medical Attendant's Name | G.H. Merrideth | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.H. Merrideth | Ames IA | Certificate Signer's Address |
| Returned by Name | G.H. Merrideth | | |