| Certificate Number | 180 | | Date Issued |
| Child Given Name | Fern |
Tedrow | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Apr 1888 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | N.S. |
Tedrow | Father's Surname |
| Father's Occupation | Engineer | | Father's Nationality |
| Father's Birth Place | Ohio | 25 | Father's Age |
| Mother's Given Name | Mary A. | Butler | Mother's Maiden Name |
| Mother's Surname | | Boone Boone Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.B. Plumb | Ames IA | Medical Attendant's Address |