| Certificate Number | 520 | | Date Issued |
| Child Given Name | |
Shear | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Nov 1882 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | Eli A. |
Shearer | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 32 | Father's Age |
| Mother's Given Name | Martha Jane | Jones | Mother's Maiden Name |
| Mother's Surname | Shearer | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar M.D. | Clyde IA | Medical Attendant's Address |
| Certificate Signer's Name | A.P. Edgar M.D. | Clyde IA | Certificate Signer's Address |
| Returned by Name | A.P. Edgar M.D. | | |