| Certificate Number | 303 | | Date Issued |
| Child Given Name | Winnifred |
Bennethum | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Sep 1889 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | Geo. D. |
Bennethum | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Pennsylvania | 37 | Father's Age |
| Mother's Given Name | Sarah | Ray | Mother's Maiden Name |
| Mother's Surname | | Nevada Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 35 | 2 | Number of Child This Mother |
| Medical Attendant's Name | Frank Thompson | Iowa Center IA | Medical Attendant's Address |