| Certificate Number | 245 | | Date Issued |
| Child Given Name | |
Brown | Child Surname |
| Child Sex | Female |
M | Child Race |
| Date of Birth | 05 Sep 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Ralph |
Brown | Father's Surname |
| Father's Occupation | Butcher | | Father's Nationality |
| Father's Birth Place | Iowa | 21 | Father's Age |
| Mother's Given Name | Minnie | Brown | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell Ia | Medical Attendant's Address |