| Certificate Number | 115 | | Date Issued |
| Child Given Name | |
Davis | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Mar 1890 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Jacob E. |
Davis | Father's Surname |
| Father's Occupation | Laborer | | Father's Nationality |
| Father's Birth Place | Indiana | 38 | Father's Age |
| Mother's Given Name | Lena | Shackelford | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 33 | 6 | Number of Child This Mother |
| Medical Attendant's Name | E.C. Scott | Maxwell Ia | Medical Attendant's Address |