| Certificate Number | 101 | | Date Issued |
| Child Given Name | Blanche Claire |
Burkhart | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 20 Feb 1889 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | C.A. |
Burkhart | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Linn Co IA | 28 | Father's Age |
| Mother's Given Name | Sarah E. | Williams | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 20 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |