| Certificate Number | 246 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Sep 1888 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Scott | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 45 | Father's Age |
| Mother's Given Name | Mary J. | Cameron | Mother's Maiden Name |
| Mother's Surname | | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 30 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |