| Certificate Number | 34 | | Date Issued |
| Child Given Name | Clara Louise |
Wilkins | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Jul 1880 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | Leny |
Wilkins | Father's Surname |
| Father's Occupation | Grain Dealer | American | Father's Nationality |
| Father's Birth Place | | 37 | Father's Age |
| Mother's Given Name | Mary A. | Guyer | Mother's Maiden Name |
| Mother's Surname | Wiilkins | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | American | | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | Geo Frazee | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo Frazee | Colo IA | Certificate Signer's Address |
| Returned by Name | 'By mail' | | |