| Certificate Number | 14 | | Date Issued |
| Child Given Name | |
Bennethum | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Sep 1887 |
Iowa Center Story Co IA | Place of Birth |
| Father's Given Name | Dan |
Bennethum | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 32 | Father's Age |
| Mother's Given Name | Rebecca | Brown | Mother's Maiden Name |
| Mother's Surname | Bennethum | Iowa Center Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 24 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |