| Certificate Number | 181 | | Date Issued |
| Child Given Name | |
Emerson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 31 Mar 1889 |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | Geo. R. |
Emerson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 34 | Father's Age |
| Mother's Given Name | Belle | Bolton | Mother's Maiden Name |
| Mother's Surname | | Gilbert Story Co iA | Mother's Residence |
| Mother's Nationality | | Wisconson | Mother's Birth Place |
| Mother's Age | 22 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |