| Certificate Number | 209 | | Date Issued |
| Child Given Name | Zora Veley |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Aug 1885 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Samuel |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 39 | Father's Age |
| Mother's Given Name | Martha E. | Craven | Mother's Maiden Name |
| Mother's Surname | Smith | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 39 | 9 | 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 | | |