| Certificate Number | 997 | | Date Issued |
| Child Given Name | |
Dewitt | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank |
Dewitt | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Illinois | 41 | Father's Age |
| Mother's Given Name | Anna | Kinsell | Mother's Maiden Name |
| Mother's Surname | Dewitt | Gilbert Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 29 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Gilbert IA | Medical Attendant's Address |
| Certificate Signer's Name | C.W. Allen | Gilbert IA | Certificate Signer's Address |
| Returned by Name | C.W. Allen | | |