| Certificate Number | 62 | | Date Issued |
| Child Given Name | |
Gossard | Child Surname |
| Child Sex | Female |
W | Child Race |
| Date of Birth | 17 Dec 1888 |
Kelley Story Co IA | Place of Birth |
| Father's Given Name | J.F. |
Gossard | Father's Surname |
| Father's Occupation | Farmer | | Father's Nationality |
| Father's Birth Place | Story Co IA | 29 | Father's Age |
| Mother's Given Name | Alice | Palmatier | Mother's Maiden Name |
| Mother's Surname | | Kelley Story Co IA | Mother's Residence |
| Mother's Nationality | | New York | Mother's Birth Place |
| Mother's Age | 26 | 3 | Number of Child This Mother |
| Medical Attendant's Name | B.D. Miller | Kelley IA | Medical Attendant's Address |