| Certificate Number | 160 | | Date Issued |
| Child Given Name | |
Scott | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 28 Mar 1889 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | E.C. |
Scott | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Josie | Dunshee | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 23 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell IA | Medical Attendant's Address |