| Certificate Number | 219 | | Date Issued |
| Child Given Name | Martha May |
Gates | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 18 Aug 1881 |
Sheldahl Story Co IA | Place of Birth |
| Father's Given Name | Brazil |
Gates | Father's Surname |
| Father's Occupation | Butcher | American | Father's Nationality |
| Father's Birth Place | Iowa | 23 | Father's Age |
| Mother's Given Name | Hannah | Small | Mother's Maiden Name |
| Mother's Surname | Gates | Sheldahl Story Co IA | Mother's Residence |
| Mother's Nationality | American | Iowa | Mother's Birth Place |
| Mother's Age | 23 | 1 | Number of Child This Mother |
| Medical Attendant's Name | J.A. Anderson | Sheldahl IA | Medical Attendant's Address |
| Certificate Signer's Name | J.A. Anderson | Sheldahl IA | Certificate Signer's Address |
| Returned by Name | J.A. Anderson | | |