| Certificate Number | 577 | | Date Issued |
| Child Given Name | |
Chaffin | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Feb 1883 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | Phillip |
Chaffin | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Ohio | 40 | Father's Age |
| Mother's Given Name | Allie Jane | Romans | Mother's Maiden Name |
| Mother's Surname | Chaffin | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Ohio | Mother's Birth Place |
| Mother's Age | 26 | 6 | Number of Child This Mother |
| Medical Attendant's Name | P. Joor | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | P. Joor | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | P. Joor | | |