| Certificate Number | 166 | | Date Issued |
| Child Given Name | Winfred |
Van Campen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Mar 1889 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Alvin |
Van Campen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New Jersey | 33 | Father's Age |
| Mother's Given Name | Elizabeth T. | Coon | Mother's Maiden Name |
| Mother's Surname | | Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 27 | 4 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |