| Certificate Number | 234 | | Date Issued |
| Child Given Name | Clara B. |
Evans | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 24 Jun 1890 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | Frank N. |
Evans | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 36 | Father's Age |
| Mother's Given Name | B.J. | Munden | Mother's Maiden Name |
| Mother's Surname | | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Indiana | Mother's Birth Place |
| Mother's Age | 35 | 3 | Number of Child This Mother |
| Medical Attendant's Name | C.A. Beverly | Ames IA | Medical Attendant's Address |