| Certificate Number | 397 | | Date Issued |
| Child Given Name | |
Stevens | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Aug 1886 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Carl C. |
Stevens | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 35 | Father's Age |
| Mother's Given Name | Florence | Gossard | Mother's Maiden Name |
| Mother's Surname | Stevens | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 25 | 2 | 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 | | |