| Certificate Number | 441 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Aug 1882 |
Union Twp Story Co IA | Place of Birth |
| Father's Given Name | E.F. |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 39 | Father's Age |
| Mother's Given Name | Fidelia | McCallister | Mother's Maiden Name |
| Mother's Surname | Scott | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 40 | 5 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes M.D. | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes M.D. | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes M.D. | | |