| Certificate Number | 97 | | Date Issued |
| Child Given Name | |
Shoemaker | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Feb 1885 |
Center Grove | Place of Birth |
| Father's Given Name | William |
Shoemaker | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 43 | Father's Age |
| Mother's Given Name | Mary Ellen | Presneal | Mother's Maiden Name |
| Mother's Surname | Shoemaker | Center Grove | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 38 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |