| Certificate Number | 498 | | Date Issued |
| Child Given Name | |
Sargeant | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Oct 1882 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | George |
Sargeant | Father's Surname |
| Father's Occupation | Farmer | English | Father's Nationality |
| Father's Birth Place | Ohio | 40 | Father's Age |
| Mother's Given Name | Josie | Bradley | Mother's Maiden Name |
| Mother's Surname | Sargeant | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Massachusets | Mother's Birth Place |
| Mother's Age | 42 | 7 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |