| Certificate Number | 217 | | Date Issued |
| Child Given Name | Marjorie |
Soule | Child Surname |
| Child Sex | |
W | Child Race |
| Date of Birth | 01 Apr 1890 |
Roland Story Co IA | Place of Birth |
| Father's Given Name | Geo. D. |
Souer | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Vermont | 30 | Father's Age |
| Mother's Given Name | Mattie | McLillan | Mother's Maiden Name |
| Mother's Surname | | Roland Story Co IA | Mother's Residence |
| Mother's Nationality | | Vermont | Mother's Birth Place |
| Mother's Age | 30 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Geo. D. Souer | Roland IA | Medical Attendant's Address |