| Certificate Number | 195 | | Date Issued |
| Child Given Name | |
Spaulding | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Sep 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | F. |
Spaulding | Father's Surname |
| Father's Occupation | Conductor | | Father's Nationality |
| Father's Birth Place | Indiana | 30 | Father's Age |
| Mother's Given Name | Ida | Ross | Mother's Maiden Name |
| Mother's Surname | Spaulding | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 27 | 5 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A. Beverly | | |