| Certificate Number | 96 | | Date Issued |
| Child Given Name | |
Benton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Jan 1888 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | J.A. |
Benton | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 22 | Father's Age |
| Mother's Given Name | Lizzie M. | Hays | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |