| Certificate Number | 1033 | | Date Issued |
| Child Given Name | |
Alderman | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Nov 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | |
Alderman | Father's Surname |
| Father's Occupation | Peddler | | Father's Nationality |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Age | | 8 | Number of Child This Mother |
| Medical Attendant's Name | A. Beverly | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | A. Beverly | Ames IA | Certificate Signer's Address |
| Returned by Name | A. Beverly | | |