| Certificate Number | 218 | | Date Issued |
| Child Given Name | Florence |
Chance | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 22 Aug 1890 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | Sumner J. |
Chance | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 22 | Father's Age |
| Mother's Given Name | Estella | Brooks | Mother's Maiden Name |
| Mother's Surname | | Zearing Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 19 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Mrs. Torrewer | Zearing IA | Medical Attendant's Address |
| Returned by Name | A.W. Brooks | | |