| Certificate Number | 440 | | Date Issued |
| Child Given Name | |
Briley | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | I. Newton |
Briley | Father's Surname |
| Father's Birth Place | Story Co IA | 34 | Father's Age |
| Mother's Given Name | Lucinda M. | Duckworth | Mother's Maiden Name |
| Mother's Surname | Briley | Washington Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 32 | | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |