| Certificate Number | 390 | | Date Issued |
| Child Given Name | Ellmer |
Green | Child Surname |
| Child Sex | Female |
| Child Race |
| Date of Birth | 1882 |
Near Zearing Story Co IA | Place of Birth |
| Father's Given Name | J. Bradley |
Green | Father's Surname |
| Father's Occupation | Farmer | American | Father's Nationality |
| Father's Birth Place | New Jersey | 47 | Father's Age |
| Mother's Given Name | Eloner | Mitchel | Mother's Maiden Name |
| Mother's Surname | Green | 1 1/2 Miles East of Zearing | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 43 | 6 | Number of Child This Mother |
| Medical Attendant's Name | A.W. Squires | Zearing IA | Medical Attendant's Address |
| Certificate Signer's Name | A.W. Squires | Zearing IA | Certificate Signer's Address |
| Returned by Name | A.W. Squires | | |