| Certificate Number | 123 | | Date Issued |
| Child Given Name | Bessie Lulu |
Wood | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 08 Jun 1885 |
Sherman Twp Story Co IA | Place of Birth |
| Father's Given Name | David P. |
Wood | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 43 | Father's Age |
| Mother's Given Name | Harriet T. | Bickford | Mother's Maiden Name |
| Mother's Surname | Wood | | Mother's Residence |
| Mother's Nationality | American | Illinois | Mother's Birth Place |
| Mother's Age | 40 | 9 | Number of Child This Mother |
| Medical Attendant's Name | J. Daughtery | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J. Daughtery | Colo IA | Certificate Signer's Address |
| Returned by Name | J. Daughtery | | |