| Certificate Number | 182 | | Date Issued |
| Child Given Name | Mary H. |
Allen | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 07 Apr 1889 |
Story City Story Co IA | Place of Birth |
| Father's Given Name | C.W. |
Allen | Father's Surname |
| Father's Occupation | Physician | | Father's Nationality |
| Father's Birth Place | North Hero VT | 33 | Father's Age |
| Mother's Given Name | Angie L. | Stewart | Mother's Maiden Name |
| Mother's Surname | | Story City Story Co IA | Mother's Residence |
| Mother's Nationality | | Bristol VT | Mother's Birth Place |
| Mother's Age | 35 | 2 | Number of Child This Mother |
| Medical Attendant's Name | C.W. Allen | Story City IA | Medical Attendant's Address |