| Certificate Number | 724 | | Date Issued |
| Child Given Name | |
Gilbert | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | |
Gilbert Story Co IA | Place of Birth |
| Father's Given Name | F.B. |
Gilbert | Father's Surname |
| Father's Occupation | Merchant | American | Father's Nationality |
| Father's Birth Place | | 31 | Father's Age |
| Mother's Given Name | Mary A. | Cook | Mother's Maiden Name |
| Mother's Surname | Gilbert | Gilbert Story Co IA | Mother's Residence |
| Mother's Nationality | American | New York | Mother's Birth Place |
| Mother's Age | 30 | 5 | Number of Child This Mother |
| Medical Attendant's Name | S.H., Mrs. Cook | Gilbert IA | Medical Attendant's Address |
| Certificate Signer's Name | S.H., Mrs. Cook | Gilbert IA | Certificate Signer's Address |
| Returned by Name | S.H., Mrs. Cook | | |