| Certificate Number | 366 | | Date Issued |
| Child Given Name | |
White | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 06 Aug 1886 |
Iowa | Place of Birth |
| Father's Given Name | P.F. |
White | Father's Surname |
| Father's Occupation | R.R. Agent | | Father's Nationality |
| Father's Birth Place | Kansas | 29 | Father's Age |
| Mother's Given Name | F.L. | More | Mother's Maiden Name |
| Mother's Surname | White | Hamilton Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 2 | Number of Child This Mother |
| Medical Attendant's Name | B.F. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |