| Certificate Number | 294 | | Date Issued |
| Child Given Name | Ella Susan |
Flora | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 14 Sep 1889 |
Maxwell Story Co IA | Place of Birth |
| Father's Given Name | Amos W. |
Flora | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Virginia | 39 | Father's Age |
| Mother's Given Name | Sarah J. | Solemberger | Mother's Maiden Name |
| Mother's Surname | | Maxwell Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 28 | 4 | Number of Child This Mother |
| Medical Attendant's Name | E.O. Scott | Maxwell Ia | Medical Attendant's Address |