| Certificate Number | 492 | | Date Issued |
| Child Given Name | |
Burton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Jan 1887 |
| Place of Birth |
| Father's Given Name | Chas E. |
Burton | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Michigan | 28 | Father's Age |
| Mother's Given Name | Rozilda | Pense | Mother's Maiden Name |
| Mother's Surname | Burton | Polk Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 24 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |