| Certificate Number | 480 | | Date Issued |
| Child Given Name | |
Spencer | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Grant Twp Story Co IA | Place of Birth |
| Father's Given Name | George Henry |
Spencer | Father's Surname |
| Father's Occupation | Farming | American | Father's Nationality |
| Father's Birth Place | Ohio | 31 | Father's Age |
| Mother's Given Name | Almalia L. | Bryant | Mother's Maiden Name |
| Mother's Surname | Spencer | Grant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | James Bradley | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | James Bradley | Ames IA | Certificate Signer's Address |
| Returned by Name | James Bradley | | |