| Certificate Number | 643 | | Date Issued |
| Child Given Name | |
Zeigler | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | J.A.M. |
Zeigler | Father's Surname |
| Father's Occupation | Minister | American | Father's Nationality |
| Father's Birth Place | Pennsylvania | 28 | Father's Age |
| Mother's Given Name | Freddie | Bell | Mother's Maiden Name |
| Mother's Surname | Zeigler | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Pennsylvania | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | J.E. Scott | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.E. Scott | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.E. Scott | | |