| Certificate Number | 794 | | Date Issued |
| Child Given Name | |
Titus | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Oct 1883 |
Huxley Story Co IA | Place of Birth |
| Father's Given Name | Limon W. |
Titus | Father's Surname |
| Father's Occupation | Station Agent | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 27 | Father's Age |
| Mother's Given Name | Albertana | Pierce | Mother's Maiden Name |
| Mother's Surname | Titus | Huxley Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 25 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.D. Hayes | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | D.D. Hayes | Cambridge IA | Certificate Signer's Address |
| Returned by Name | D.D. Hayes | | |