| Certificate Number | 75 | | Date Issued |
| Child Given Name | Cordia V. |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 19 Jan 1889 |
Kelley Story Co IA | Place of Birth |
| Father's Given Name | Sam'l |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 42 | Father's Age |
| Mother's Given Name | Martha | Cravens | Mother's Maiden Name |
| Mother's Surname | | Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 42 | 12 | Number of Child This Mother |
| Medical Attendant's Name | B.D. Miller | Kelley IA | Medical Attendant's Address |