| Certificate Number | 477 | | Date Issued |
| Child Given Name | Miss |
Carver | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Carver | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 40 | Father's Age |
| Mother's Given Name | Fanny | Bowsie | Mother's Maiden Name |
| Mother's Surname | Carver | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | English | England | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton M.D. | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | F.S Newton M.D. | Zearing IA | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |