| Certificate Number | 5 | | Date Issued |
| Child Given Name | |
Burleigh | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 09 Aug 1891 |
Washington Twp Story Co IA | Place of Birth |
| Father's Given Name | Charles H. |
Burleigh | Father's Surname |
| Father's Occupation | Clergyman | | Father's Nationality |
| Father's Birth Place | Iowa | 42 | Father's Age |
| Mother's Given Name | Ruth E. | Kendall | Mother's Maiden Name |
| Mother's Surname | Burleigh | Valentine Nebraska | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 41 | 5 | Number of Child This Mother |
| Medical Attendant's Name | A Richmond | Ames IA | Medical Attendant's Address |