| Certificate Number | 1 | | Date Issued |
| Child Given Name | |
Chaplin | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Oct 1884 |
Story Co IA | Place of Birth |
| Father's Given Name | Jacob |
Chaplin | Father's Surname |
| Father's Birth Place | New York State | 51 | Father's Age |
| Mother's Given Name | Biddie D. | Chaffin | Mother's Maiden Name |
| Mother's Surname | Chaplin | Union Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 40 | 7 | Number of Child This Mother |
| Medical Attendant's Name | J.M. Brown | Cambridge IA | Medical Attendant's Address |
| Certificate Signer's Name | J.M. Brown | Cambridge IA | Certificate Signer's Address |
| Returned by Name | J.M. Brown | | |