| Child Given Name | |
Smith | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | |
2 Miles West of Zearing IA | Place of Birth |
| Father's Given Name | Jacob B. |
Smith | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 53 | Father's Age |
| Mother's Given Name | Elizabeth | Biegman | Mother's Maiden Name |
| Mother's Surname | Smith | | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 44 | 10 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Squires | | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Squires | | Certificate Signer's Address |
| Returned by Name | A.W. Squires | | |