| Certificate Number | 402 | | Date Issued |
| Child Given Name | |
Sills | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Sep 1886 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Wm. |
Sills | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 20 | Father's Age |
| Mother's Given Name | Estella | Stoops | Mother's Maiden Name |
| Mother's Surname | Sills | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Missouri | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | E.B. Plumb | Ames IA | Certificate Signer's Address |
| Returned by Name | E.B. Plumb | | |