| Certificate Number | 364 | | Date Issued |
| Child Given Name | |
Carter | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Jun 1886 |
Story Co IA | Place of Birth |
| Father's Given Name | G.G. |
Carter | Father's Surname |
| Father's Occupation | Butter Maker | | Father's Nationality |
| Father's Birth Place | Kentucky | 32 | Father's Age |
| Mother's Given Name | Mary | McNichols | Mother's Maiden Name |
| Mother's Surname | Carter | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 30 | 6 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Story City IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |