| Certificate Number | 194 | | Date Issued |
| Child Given Name | |
Carver | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 10 Jun 1888 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Carver | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 47 | Father's Age |
| Mother's Given Name | Fannie | Bausor | Mother's Maiden Name |
| Mother's Surname | | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | England | Mother's Birth Place |
| Mother's Age | 34 | 5 | Number of Child This Mother |
| Medical Attendant's Name | F.S. Newton | Zearing IA | Medical Attendant's Address |