| Certificate Number | 457 | | Date Issued |
| Child Given Name | |
Simmons | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Sep 1882 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Roman Ira |
Simmons | Father's Surname |
| Father's Occupation | Horse Dealer | American | Father's Nationality |
| Father's Birth Place | Illinois | 29 | Father's Age |
| Mother's Given Name | Frances E. | Ostranger | Mother's Maiden Name |
| Mother's Surname | Simmons | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Jane L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | Jane L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | Jane L., Mrs. Bartlett | | |