| Certificate Number | 220 | | Date Issued |
| Child Given Name | Mary Elizabeth |
Campbell | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Aug 1890 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Charles |
Campbell | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | New York | 37 | Father's Age |
| Mother's Given Name | Nina | Stratton | Mother's Maiden Name |
| Mother's Surname | | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Story Co IA | Mother's Birth Place |
| Mother's Age | 25 | 3 | Number of Child This Mother |
| Medical Attendant's Name | E.H. Monk | Nevada IA | Medical Attendant's Address |