| Certificate Number | 649 | | Date Issued |
| Child Given Name | |
Vincent | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Jun 1883 |
Polk Co IA | Place of Birth |
| Father's Given Name | David N. |
Vincent | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 30 | Father's Age |
| Mother's Given Name | Florence A. | Gifford | Mother's Maiden Name |
| Mother's Surname | Vincent | Polk Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 2 | 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 | | |