| Certificate Number | 290 | | Date Issued |
| Child Given Name | |
Deen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Aug 1889 |
Warren Twp Story Co IA | Place of Birth |
| Father's Given Name | Jno. W. |
Deen | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | McLean Co IL | 43 | Father's Age |
| Mother's Given Name | Mary J. | Stauchfield | Mother's Maiden Name |
| Mother's Surname | | Warrant Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Maine | Mother's Birth Place |
| Mother's Age | 36 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |