| Certificate Number | 256 | | Date Issued |
| Child Given Name | |
Blackburn | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Feb 1886 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Wm |
Blackburn | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 23 | Father's Age |
| Mother's Given Name | Russ | Wantz | Mother's Maiden Name |
| Mother's Surname | Blackman | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton | | |