| Certificate Number | 499 | | Date Issued |
| Child Given Name | |
Williams | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | George Davis |
Williams | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Iowa | 28 | Father's Age |
| Mother's Given Name | Mary N. | Shoemaker | Mother's Maiden Name |
| Mother's Surname | Williams | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 27 | 1 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S. Newton M.D. | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |