| Certificate Number | 10 | | Date Issued |
| Child Given Name | Juneta May |
Guge | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 21 Jul 1880 |
Indian Creek Twp Story Co IA | Place of Birth |
| Father's Given Name | James |
Guge | Father's Surname |
| Father's Occupation | Wood Chopper | American | Father's Nationality |
| Father's Birth Place | Indiana | 49 | Father's Age |
| Mother's Given Name | Julia A. | Layton | Mother's Maiden Name |
| Mother's Surname | Guge | Indian Creek Twp Story Co IA | Mother's Residence |
| Mother's Nationality | American | Indiana | Mother's Birth Place |
| Mother's Age | 47 | 5 | Number of Child This Mother |
| Medical Attendant's Name | E., Dr. Bowen | Iowa Center IA | Medical Attendant's Address |
| Certificate Signer's Name | E., Dr. Bowen | Iowa Center IA | Certificate Signer's Address |
| Returned by Name | E., Dr. Bowen | | |