| Certificate Number | 215 | | Date Issued |
| Child Given Name | |
Carr | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Jun 1889 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Lewis |
Carr | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Indiana | 28 | Father's Age |
| Mother's Given Name | Dessa | Shaw | Mother's Maiden Name |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 2 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |