| Certificate Number | 195 | | Date Issued |
| Child Given Name | Eva |
Ambrose | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Sep 1885 |
Colo Story Co IA | Place of Birth |
| Father's Given Name | J.W. |
Ambrose | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | Virginia | 50 | Father's Age |
| Mother's Given Name | Lucy J. | McNair | Mother's Maiden Name |
| Mother's Surname | Ambrose | Colo Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 41 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Jno I. Hostetter | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | Jno I. Hostetter | Colo IA | Certificate Signer's Address |
| Returned by Name | Jno I Hostetter | | |