| Certificate Number | 129 | | Date Issued |
| Child Given Name | |
Fortune | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 11 Feb 1884 |
Ames Story Co IA | Place of Birth |
| Father's Given Name | M. |
Fortune | Father's Surname |
| Father's Occupation | Comcl Traveler | | Father's Nationality |
| Father's Birth Place | Virginia | 41 | Father's Age |
| Mother's Given Name | Ada | Parsons | Mother's Maiden Name |
| Mother's Surname | Fortune | Ames Story Co IA | Mother's Residence |
| Mother's Nationality | | Pennsylvania | Mother's Birth Place |
| Mother's Age | 28 | 2 | Number of Child This Mother |
| Medical Attendant's Name | D.S. Fairchild | Ames IA | Medical Attendant's Address |