| Certificate Number | 293 | | Date Issued |
| Child Given Name | |
Benedict | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 16 Sep 1889 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Geo. |
Benedict | Father's Surname |
| Father's Occupation | Druggist | | Father's Nationality |
| Father's Birth Place | New York | 39 | Father's Age |
| Mother's Given Name | Cora E. | Moore | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 32 | 2 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell Ia | Medical Attendant's Address |