| Certificate Number | 40 | | Date Issued |
| Child Given Name | |
Gibson | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 01 Dec 1887 |
Franklin Twp Story Co IA | Place of Birth |
| Father's Given Name | James A. |
Gibson | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Iowa | 25 | Father's Age |
| Mother's Given Name | Millie | Cox | Mother's Maiden Name |
| Mother's Surname | | Franklin Twp Story Co IA | Mother's Residence |
| Mother's Nationality | | Iowa | Mother's Birth Place |
| Mother's Age | 21 | 1 | Number of Child This Mother |
| Medical Attendant's Name | H.M. Templeton | Ames IA | Medical Attendant's Address |