| Certificate Number | 36 | | Date Issued |
| Child Given Name | |
Charlton | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Lafayette Twp Story Co IA | Place of Birth |
| Father's Given Name | N.D. |
Charlton | Father's Surname |
| Father's Occupation | R.R. Brakeman | | Father's Nationality |
| Father's Birth Place | Canada | 24 | Father's Age |
| Mother's Given Name | Margaret | Mathews | Mother's Maiden Name |
| Mother's Surname | Charlton | Lafayette Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | B.F Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | B.F. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | B.F. Allen | | |