| Certificate Number | 64 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Dec 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | J.S. |
Smith | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Ireland | 36 | Father's Age |
| Mother's Given Name | Jessie M. | Burkhart | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Linn Co IA | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg | Medical Attendant's Address |