| Certificate Number | 151 | | Date Issued |
| Child Given Name | Jessie Leo |
Edgar | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 30 Apr 1885 |
Collins Story Co IA | Place of Birth |
| Father's Given Name | Asbury P. |
Edgar | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | Newton IA | 35 | Father's Age |
| Mother's Given Name | Mary A. | Thompson | Mother's Maiden Name |
| Mother's Surname | Edgar | Collins Story Co IA | Mother's Residence |
| Mother's Nationality | | Clyde IA | Mother's Birth Place |
| Mother's Age | 28 | 3 | Number of Child This Mother |
| Medical Attendant's Name | A.P. Edgar | Collins IA | Medical Attendant's Address |
| Certificate Signer's Name | A.P. Edgar | Collins IA | Certificate Signer's Address |
| Returned by Name | A.P. Edgar | | |