| Certificate Number | 224 | | Date Issued |
| Child Given Name | Alice May |
Childs | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 20 Aug 1881 |
Nevada Story Co IA | Place of Birth |
| Father's Given Name | Leroy R. |
Childs | Father's Surname |
| Father's Occupation | Laborer | American | Father's Nationality |
| Father's Birth Place | Bath NH | 25 | Father's Age |
| Mother's Given Name | Lucy | Crippen | Mother's Maiden Name |
| Mother's Surname | Childs | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | American | Worcester NY | Mother's Birth Place |
| Mother's Age | 21 | 3 | Number of Child This Mother |
| Medical Attendant's Name | J.S. Lowell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | J.S. Lowell | Nevada IA | Certificate Signer's Address |
| Returned by Name | J.S. Lowell | | |