| Certificate Number | 66 | | Date Issued |
| Child Given Name | Mable |
Evans | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Oct 1880 |
Milford Twp Story Co IA | Place of Birth |
| Father's Given Name | Theodor B. |
Evans | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Milford Twp Story Co IA | 27 | Father's Age |
| Mother's Given Name | Nina | Harbour | Mother's Maiden Name |
| Mother's Surname | Evans | Milford Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Davis Co IA | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | H.M. Templeton | Ames IA | Certificate Signer's Address |
| Returned by Name | H.M. Templeton | | |