| Certificate Number | 293 | | Date Issued |
| Child Given Name | Charlotte Amelia |
Adams | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 31 Dec 1881 |
Lincoln Twp Story Co IA | Place of Birth |
| Father's Given Name | John |
Adams | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New Hampshire | 46 | Father's Age |
| Mother's Given Name | Augusta | Crain | Mother's Maiden Name |
| Mother's Surname | Adams | Lincoln Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | New Hampshire | Mother's Birth Place |
| Mother's Age | 39 | 6 | Number of Child This Mother |
| Certificate Signer's Name | F.S. Newton M.D. | | Certificate Signer's Address |
| Returned by Name | F.S. Newton M.D. | | |