| Certificate Number | 559 | | Date Issued |
| Child Given Name | |
Cook | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 04 Jun 1887 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | Nelson Gaston |
Cook | Father's Surname |
| Father's Occupation | Photographer | | Father's Nationality |
| Father's Birth Place | Illinois | 41 | Father's Age |
| Mother's Given Name | Alvah Hale | Shields | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Illinois | Mother's Birth Place |
| Mother's Age | 39 | 6 | Number of Child This Mother |
| Medical Attendant's Name | Jane L., Mrs. Bartlett | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | Jane L., Mrs. Bartlett | Ames IA | Certificate Signer's Address |
| Returned by Name | Jane L., Mrs Bartlett | | |