| Certificate Number | 222 | | Date Issued |
| Child Given Name | |
Drake | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Aug 1890 |
Nevada Twp Story Co IA | Place of Birth |
| Father's Given Name | W.H. |
Drake | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Ohio | 26 | Father's Age |
| Mother's Given Name | Ida M. | McKinney | Mother's Maiden Name |
| Mother's Surname | | Nevada Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 20 | 1 | Number of Child This Mother |
| Medical Attendant's Name | Sylvia Drake | | Medical Attendant's Address |