| Certificate Number | 256 | | Date Issued |
| Child Given Name | Gertrude |
Evans | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Oct 1881 |
Franklin 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 | Iowa | 28 | Father's Age |
| Mother's Given Name | Nina | Harbour | Mother's Maiden Name |
| Mother's Surname | Evans | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 22 | 2 | 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 | | |