| Certificate Number | 44 | | Date Issued |
| Child Given Name | |
French | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Oct 1880 |
New Albany Twp Story Co IA | Place of Birth |
| Father's Given Name | Chas A. |
French | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | Jasper Co IA | 25 | Father's Age |
| Mother's Given Name | Matilda J. | Haynes | Mother's Maiden Name |
| Mother's Surname | French | New Albany Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Wright Co IA | Mother's Birth Place |
| Mother's Age | 24 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J. Daugherty | Colo IA | Medical Attendant's Address |
| Certificate Signer's Name | J. Daugherty | Colo IA | Certificate Signer's Address |
| Returned by Name | 'Mail' | | |