| Certificate Number | 776 | | Date Issued |
| Child Given Name | Genevieve |
Stevens | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 May 1881 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | John L. |
Stevens | Father's Surname |
| Father's Occupation | Lawyer | American | Father's Nationality |
| Father's Birth Place | Vermont | 31 | Father's Age |
| Mother's Given Name | Rowend E. | Edson | Mother's Maiden Name |
| Mother's Surname | Stevens | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wisconson | Mother's Birth Place |
| Mother's Age | 29 | | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |