| Certificate Number | 171 | | Date Issued |
| Child Given Name | |
Chenowith | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 25 Sep 1885 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | J.H. |
Chenowith | Father's Surname |
| Father's Occupation | Cashier | | Father's Nationality |
| Father's Birth Place | Iowa | 26 | Father's Age |
| Mother's Given Name | Frances C. | Newhaus | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 27 | 1 | Number of Child This Mother |
| Medical Attendant's Name | G.A. Meridith | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | G.A. Meridith | Ames IA | Certificate Signer's Address |
| Returned by Name | G.A. Meridith | | |