| Certificate Number | 177 | | Date Issued |
| Child Given Name | Pearl Elmer |
Womack | Child Surname |
| Child Sex | Male |
W | Child Race |
| Date of Birth | 12 May 1881 |
Collins Twp Story Co IA | Place of Birth |
| Father's Given Name | James Franklin |
Womack | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 31 | Father's Age |
| Mother's Given Name | Lydia M. | Shearer | Mother's Maiden Name |
| Mother's Surname | Womack | Collins Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar | Clyde Jasper Co IA | Medical Attendant's Address |
| Certificate Signer's Name | A.P. Edgar | Clyde Jasper Co IA | Certificate Signer's Address |
| Returned by Name | A.P. Edgar | | |