| Certificate Number | 231 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Apr 1890 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Thos. C. |
Smith | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 31 | Father's Age |
| Mother's Given Name | Sarah T. | Thompson | Mother's Maiden Name |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |