| Certificate Number | 117 | | Date Issued |
| Child Given Name | |
Simmons | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 May 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Perry |
Simmons | Father's Surname |
| Father's Occupation | Horseman | American | Father's Nationality |
| Father's Birth Place | Illinois | 25 | Father's Age |
| Mother's Given Name | Anna | Oslamder | Mother's Maiden Name |
| Mother's Surname | Simmons | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | 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 | | |