| Certificate Number | 6 | | Date Issued |
| Child Given Name | |
Smith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Apr 1891 |
Gilbert Station Story Co IA | Place of Birth |
| Father's Given Name | Leander |
Smith | Father's Surname |
| Father's Occupation | Cheese Maker | | Father's Nationality |
| Father's Birth Place | New York | 39 | Father's Age |
| Mother's Given Name | Dora | Farrell | Mother's Maiden Name |
| Mother's Surname | Smith | Gilbert Station Story Co IA | Mother's Residence |
| Mother's Nationality | | Johnson Co IA | Mother's Birth Place |
| Mother's Age | 29 | 2 | Number of Child This Mother |
| Medical Attendant's Name | A. Richmond M.D. | Ames IA | Medical Attendant's Address |