| Certificate Number | 219 | | Date Issued |
| Child Given Name | Mabel |
Brooks | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 23 Sep 1890 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | A.W. |
Brooks | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Illinois | 42 | Father's Age |
| Mother's Given Name | Henrietta | Lewis | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 40 | 5 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |