| Certificate Number | 460 | | Date Issued |
| Child Given Name | |
Chance | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 05 Nov 1886 |
Zearing Story Co IA | Place of Birth |
| Father's Given Name | Jonathan |
Chance | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 46 | Father's Age |
| Mother's Given Name | Sarah | Pope | Mother's Maiden Name |
| Mother's Surname | Chance | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 35 | 7 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Brooks | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Brooks | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Brooks | | |