| Certificate Number | 454 | | Date Issued |
| Child Given Name | Sarah Viola |
Scott | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Nov 1886 |
Palestine Twp Story Co IA | Place of Birth |
| Father's Given Name | Sylvester |
Scott | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 32 | Father's Age |
| Mother's Given Name | Sarah Ann | Elliott | Mother's Maiden Name |
| Mother's Surname | Scott | Palestine Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 31 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |