| Certificate Number | 216 | | Date Issued |
| Child Given Name | Florence M. |
Fullman | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 27 Feb 1883 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | George |
Fullman | Father's Surname |
| Father's Occupation | Merchant | | Father's Nationality |
| Father's Birth Place | New York | 25 | Father's Age |
| Mother's Given Name | Mabel | Potter | Mother's Maiden Name |
| Mother's Surname | Fullman | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Ohio | Mother's Birth Place |
| Mother's Age | 26 | 1 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |
| Certificate Signer's Name | D.S. Fairchild | Ames IA | Certificate Signer's Address |
| Returned by Name | D.S. Fairchild | | |