| Certificate Number | 1040 | | Date Issued |
| Child Given Name | Mahal |
Van Camp | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 May 1884 |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | Alvin |
Van Camp | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | | 26 | Father's Age |
| Mother's Given Name | Libby | Coon | Mother's Maiden Name |
| Mother's Surname | Van Camp | Gilbert Story Co IA | Mother's Residence |
| Mother's Age | 22 | 1 | Number of Child This Mother |
| Medical Attendant's Name | C.A., Dr. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | C.A., Dr. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | C.A., Dr. Beverly | | |