| Certificate Number | 515 | | Date Issued |
| Child Given Name | |
Adams | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | Apr 1887 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Daniel |
Adams | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 30 | Father's Age |
| Mother's Given Name | Fannie Belle | | Mother's Maiden Name |
| Mother's Surname | Adams | | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 25 | 5 | Number of Child This Mother |
| Medical Attendant's Name | Geo. Stitzell | Nevada IA | Medical Attendant's Address |
| Certificate Signer's Name | Geo. Stitzell | Nevada IA | Certificate Signer's Address |
| Returned by Name | Geo. Stitzell | | |