| Certificate Number | 116 | | Date Issued |
| Child Given Name | |
Adams | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Feb 1889 |
Richland Twp Story Co IA | Place of Birth |
| Father's Given Name | Daniel A. |
Adams | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Illinois | 33 | Father's Age |
| Mother's Given Name | Fannie | Holmes | Mother's Maiden Name |
| Mother's Surname | | Richland Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 27 | 6 | Number of Child This Mother |
| Medical Attendant's Name | J.W. Osborn | McCallsburg IA | Medical Attendant's Address |