| Certificate Number | 194 | | Date Issued |
| Child Given Name | Cecile |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 15 Dec 1889 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Marcellus K. |
Smith | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 31 | Father's Age |
| Mother's Given Name | Laura | West | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 30 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |